- Email: [email protected]
Nurses' viewpoint about the impact of Kangaroo Mother Care on the mother–infant attachment
Journal of Neonatal Nursing (2013) 19, 38e43
www.elsevier.com/jneo
Nurses’ viewpoint about the impact of Kangaroo Mother Care on the mothereinfant attachment Leila Valizadeh a,1,2, Najmeh Ajoodaniyan a,1,2, Mahboobeh Namnabati a,*,2, Vahid Zamanzadeh b,1,2, Vahideh layegh c,2 a
Department of Child and Family Health, Tabriz University of Medical Sciences, Tabriz, Iran Medical and Surgical Department, Tabriz University of Medical Sciences, Tabriz, Iran c Al-Zahra Hospital, Tabriz University of Medical Sciences, Tabriz, Iran b
Available online 9 June 2012
KEYWORDS Kangaroo Mother Care; Attachment; NICU; Viewpoint
Abstract Aim: The aim of this investigation was to determine nurses’ viewpoint about the impact of Kangaroo Mother Care on the attachment between mother and infant. Methods: A descriptive study was carried out with the staff (23 nurses) of an NICU of a University Hospital in Iran. Data were collected through self-report method (Avant Maternal Attachment Behavior Scale) and analyzed by use of SPSS. Findings: The majority of the participants had positive viewpoint on the subject of study. The affectionate behavioral subscale had the most effect on the mothereinfant attachment, while the item “holding without skin contact” of proximity maintaining subscale was looked at as the most disagree and strongly disagree item (68.2%) of the attachment scale. Conclusion: According to the nurses’ viewpoints, mothereinfant attachment behavior are strengthened by applying the Kangaroo Mother Care. Furthermore, the benefits of this type of care are mentioned. ª 2012 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ98 311 6688965. E-mail addresses: [email protected] (L. Valizadeh), [email protected] (N. Ajoodaniyan), [email protected] (M. Namnabati), [email protected] (V. Zamanzadeh), [email protected] (V. layegh). 1 Tel.: þ98 411 4796770. 2 All authors were involved in study for design, data collection, analysis, drafting of manuscript, critical revisions, and statistical expertise. 1355-1841/$ - see front matter ª 2012 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jnn.2012.05.004
Impact of Kangaroo Mother Care
Introduction Attachment is a unique relationship between the parents and the infant (Kenner and McGrath, 2004). It begins in prenatal period when the fetus grows inside mother’s body; and after the birth when the mother gradually recognizes infant’s cues, adapts to his/her behavior, and tries to meet the needs of her infant (Johnson, 2008). This reciprocity parentseinfant relationship, as an essential element of the attachment process, helps satisfying both the mother and the infant (Kenner and McGrath, 2004). Kangaroo Mother Care (KMC) facilitates the process as more convenient as possible (Gathwala et al., 2008). Studies indicate that the advantages of skin-toskin contact can cause infant’s physiologic stability such as regulating body temperature, improving oxygen saturation levels, and reducing apnea (Cong et al., 2011). It improves the exclusive breastfeeding period which results in more milk production and weight gained, and earlier discharge of mother and infant (Hunt, 2008; Johnston et al., 2003). KMC also can help reducing infant’s response to pain and childhood behavioral problems (Bohnhorst et al., 2001; Ludington-Hoe et al., 1999; Mori et al., 2010). Despite the above and many other advantages of the KMC, there are some barriers with its application such as safety, staff reluctance and shortage, insufficient education, lack of organizational support, and the absence of pertinent protocols which prevent enforcing the care in the NICU (Chia et al., 2006). Hospitalization may also delay the attachment and impede the mothereinfant relationship. To solve the problem, KMC can establish the attachment by physical contact between the preterm newborn and the mother in the NICU (Franklin, 2006; Johnson, 2008; Karabel et al., 2011). Consequently, it strengthens the quality of the parenteinfant relationship psychologically, socially, and emotionally and also affects the long-term outcome of growth and development. On the contrary, it should be tangibly noted that the attachment disorder, as a product of maternal separation or lack of mother care may lead in complications such as failure to thrive, separation anxiety disorder, personality disorder, school problems, crime and so on (Karabel et al., 2011; Ludington-Hoe et al., 1999). It was estimated that 9.6% of all births worldwide were preterm. Approximately 85% of these preterm births were concentrated in Africa and Asia (Beck et al., January 2010). According to the reports of medical sciences universities in Iran,
39 7.2% of total births were preterm (Solimani and SolIran, 2007). Two-third of all neonatal deaths occurred in low birth weight. KMC was found to reduce morbidity and mortality in low birth weight infants (Conde-Agudelo et al., 2011). Nurse plays a crucial role in the care of infant and helps the mother to promote her attachment behavior with the infant in the NICU (Johnson, 2008). Their mothers were instructed for applying KMC. KMC has been being applied since 2005 in the only equipped high-tech NICU of a University Hospital in NortheWest of Iran. Authorities have planned to apply the KMC through some workshops, to be held for all nurses working there. The focus has been made on the effects of KMC on neonates in pervious studies (Boo and Jamli, 2007; Parmar et al., 2009; Tessier et al., 2003). But no investigation has been done about the staff’s attitude toward the effect of this procedure on the attachment in Iran. Researchers believe that the nurse’s attitude can affect her performance and collaboration with the mother in using KMC. The purpose of this study was to determine nurses’ viewpoint about the impact of applying KMC on mothereinfant attachment in the NICU.
Methods Participants and setting A descriptive study was conducted in a university hospital in Tabriz, Iran in 2010. All 23 invited nurses were the staff of the unit. They had already worked in three levels of the NICU for six months or more and had performed KMC for at least ten times.
Instrument Data were collected by use of a two-part questionnaire. The first part included demographic information of participants such as age, sex, work experience and etc. The second part was a modified Avant Maternal Attachment Behavior Scale to assess the mothereinfant attachment. It consists of self-report questionnaire of 13 items on 5-point Likert-type scales ranging from 1 (strongly disagree) to 5 (strongly agree). It was divided into three subscales: A) the affectionate behavior (looking, kissing, talking, smiling, rocking, touching, and full attention), B) the proximity maintaining subscale (holding without skin contact, encompassing in both arms and close contact), and C) the caretaking behavior (diaper
40
L. Valizadeh et al.
changing, burping, and undressing). Also, a general question was asked about KMC and its effects. All nurses completed and returned the questionnaires. Translation accuracy of the attachment scale was considered. Cronbach’s alpha was used to determine the reliability and examine the correlation between the items of the scale and it was 0.7.
Data analysis and ethical issues Data analysis was performed with the SPSS, version 17. Descriptive statistics such as frequency, percentage, mean, and standard deviation were calculated and Freidman test was carried out too as a non-parametric test. Permission to conduct the study was obtained from the ethics committee of the Tabriz University of Medical sciences and a written consent was taken from every participant.
Findings All of the participants were NICU nurse employees and had worked in all shifts in turnover. All of them (100%) had learned the principals of KMC through continuing education and had repeatedly performed it as a task. They had clinical experience in all shifts for at least six months to maximum 12 years (Table 1). There were three subscales in the modified Avant Maternal Attachment Behavior Scale which measured nurses’ viewpoints about the effects of KMC on the attachment. Findings revealed a positive viewpoint in all subscales (M ¼ 4.08 0.36). Freidman test showed that affection behavior subscale had the most positive viewpoint among the other three subscales (Mean rank ¼ 2.61). It
Table1
Demographic variables of nurses.
Characteristics of parents
Number
(%)
Mean (year)
SD
Sex (Female) Age Clinical experience Marital status Married Single Having children Yes No Graduation state Bachelor Nursing diploma
23 23 23
(100) (100) (100)
e 32.8 6.5
e 5.3 2.6
18 5
(78.3) (21.7)
e e
e e
17 6
(74) (26)
e e
e e
22 1
(95) (5)
e e
e e
was widely believed that KMC had a major impact on the affectionate behavior and touching was viewed to have 100% agreement by nurses. The caretaking behavior subscale was thought to have the least effect among these subscales and burping among the other items had the weakest agreement from the nurses (26.1%). The item “encompassing in both arms” had the most agreement from the nurses (95%) in the proximity maintaining subscale. Nurses were agreed and even strongly agreed with more than 75% of items such as encompassing in both arms, smiling, undressing, and kissing respectively. Interestingly, it was reported that the majority of nurses (68.2%) were disagreed and strongly disagreed with holding without skin contact by the mother. Touching, encompassing in both arms, and undressing took an overall score of more than 90% of agreement and strongly agreement of the nurses in the three subscales in the modified Avant Maternal Attachment Behavior Scale (Table 2). As an answer to one general question, all participants mentioned a variety of beneficial effects of applying KMC in NICU since 2005. The 90% of the responses showed an increase in mother’s affection, better mothereneonate relationship, mother’s presence in the unit, consoling neonate, calming mother, involvement in neonate’s care such as bathing and feeding.
Discussion This study clarified a comprehensive picture of neonatal nurses’ viewpoint about the impact of applying KMC on the attachment behavioral scale in recent years. The majority of nurses had positive view toward the most items of attachment scales. Similarly, studies reported that the majority of nurses had positive attitudes to the use of KMC (Chia et al., 2006; McCord, 2011; Settle et al., 2002) and mothers had a significantly higher attachment score in the KMC group than mothers in control group (Gathwala et al., 2008). Thus, positive attitude could have led to strong support of applying KMC as a daily routine care (Ramanathan et al., 2001). According to the nurses’ viewpoint, 12 of 13 items were strengthened after applying KMC. Touching was considered as the most important item in the attachment scale. In a review study, it was shown that the positive effects of touch improve emotional bonding and physiologic stability such as thermoregulation, gaining weight, better sleep-wake pattern, enhanced neuromotor development (Kulkarni et al., 2010). KMC, a model
Impact of Kangaroo Mother Care Table 2
41
Frequency distribution nurses’ viewpoint of impact of KMC on mothereinfant attachment.
Items A. Affectionate behaviors Looking Touching Kissing Talking Smiling Rocking Full attention B. Proximity maintaining Holding without skin contact Encompassing in both arms Close contact C. The caretaking behaviors Diaper changing Burping Undressing
Strongly agree (%)
Agree (%)
Do not know (%)
Disagree (%)
Strongly disagree (%)
Mean SD (%)
87 91.3 39.1 78.3 82.6 18.2 30
8.7 8.7 34.8 17.4 8.7 36.4 35
4.3 e 8.7 4.3 8.7 22.7 15
e e 13 e e 18.2 20
e e 4.3 e e 4.5 e
4.78 4.89 3.84 4.78 4.78 3.42 3.73
9.1
9.1
13.6
40.9
27.3
2.31 1.24
59.1 59.1
36.4 36.4
4.5 4.5
e e
e e
3.90 0.97 4.54 0.59
39.1 26.1 31.8
30.4 39.1 59.1
17.4 13 9.1
13 5 e
e e e
4.04 0.99 3.68 1.12 4.22 0.61
of care, regulates nerve system that leads to decreased stress for both mother and infant (Ferber and Makhoul, 2004). This interventional care can motivate the mother to be a more passionate and enthusiastic mother (Harrison N and Woods, 1991; Johnson, 2005). In some NICUs, mothers are encouraged to use Kangaroo Care to have skin contact, not only to just warm but rather to stimulate touching, smelling, hearing, and feeling closer to the baby as well (Franklin, 2006). A survey showed that a 15e20 min skin contact made the mother the fortune to have time for kissing and looking at her baby. Another study confirmed that using KMC, mothers had more verbal and nonverbal behavior such as laughing, hugging, and checking the baby (Tilokskulchai et al., 2002). In current study, the majority of the participants disagreed with the item "holding without skin contact". It seems that the nurses couldn’t imagine KMC without skin-to-skin contact. In general, in respond to the question about the effects of KMC, nurses counted several benefits of the care such as increasing maternal affection and involving the mother in taking care of the baby. Personnel were instructed to emphasize on the presence of mothers at the unit for applying KMC. Consequently, they were to take care of their babies unwillingly in much of their day time. Studies confirmed that being in the NICU around the clock and having the role of a partner, the mother can improve attachment and caring and expedite the discharge from NICU (Bakewell-Sachs and Gennaro, 2004; Nyqvist and Engvall, 2009).
0.53 0.31 1.16 0.41 0.53 1.21 1.14
Despite increasing evidence for benefits of KMC, some studies have indicated barriers to applying KMC such as lack of policies for KMC implementation and insufficient academic integration. The implementation barriers and understanding the circumstances of KMC were identified in 25 developing countries. The researchers presented several themes which caregivers express as negative aspects of KMC including: discomfort in placing the infant on the bare chest, a perceived lack of privacy, difficulty in maintaining thermal control, and cultural differences related to diapering (Charpak and Gabriel Ruiz-Pela ´ez, 2006; Settle et al., 2002). In addition, it needs more staff, sufficient education, and organizational support, especially for low birth weight infants (Chia et al., 2006). Knowing that their attitude and role can affect parents’ tends to perform KMC, NICU nurses teach the parents the KMC method as a daily task (Blomqvist et al., 2011). In fact, their positive and realistic attitude support parents and ease the early attachment (Kearvell and Grant, 2010). Nurses play a unique role in improving mothereinfant interaction through KMC in order to encourage breastfeeding and participation in routine care. Alongside, the psychosocial support and the effective, communication established in motherenurse interaction, are vital in connections between the mother and her infant (Parisi et al., 2008). The small sample size was a limitation to the study. However, with regards to increased use of KMC in the recent years in Iran, it was worth to
42 assess the attitude of nurses. It is suggested to explore the feasibility, obstacles and solutions to the application of KMC for under ventilated preterm infants in the next study. The impact of KMC could also be of worth to evaluate the attachment between the father and the infant in our culture. On account of knowing little about the long-term outcomes of KMC, it is also recommended to perform a research about the outcomes of KMC based on the different context or culture.
Conclusion The result of this study confirms that the nurses had a strong positive viewpoint on the use of KMC in NICU. All of them mentioned that mothers and infants have taken benefits of KMC since it has been applied in the NICU in Iran. Interestingly, the affection behavioral subscale was the important aspect which affects the attachment. Nurses believed that this method of caring supports developmental care, and improves the attachment between mother and infant.
Acknowledgments With thanks to the cooperation of research bureau of Tabriz University of Medical Science and AlZahra Hospital. The authors would like to thank the nurses who participated in this study.
References Bakewell-Sachs, S., Gennaro, S., 2004. Parenting the post-NICU premature infant. MCN: The American Journal of Maternal/ Child Nursing 29, 398. Beck, S., Wojdyla, D., Say, L., Betran, A., Mario, M., Requejo, J., Rubens, C., Menon, R., V.L, P., January 2010. The Worldwide Incidence of Preterm Birth: a Systematic Review of Maternal Mortality and Morbidity, pp. 1e80. Blomqvist, Y.T., Rubertsson, C., Frolund, L., Nyqvist, K.H., 2011. Provision of Kangaroo Mother Care: Facilators and Barriers Neo-BFHI. Uppsala Universitet, Uppsala, Sweden, p. 27. Bohnhorst, B., Heyne, T., Peter, C.S., Poets, C.F., 2001. Skin-toskin (kangaroo) care, respiratory control, and thermoregulation. Journal of Pediatrics 138, 193e197. Boo, N.Y., Jamli, F.M., 2007. Short duration of skin-to-skin contact: effects on growth and breastfeeding. Journal of Paediatrics and Child Health 43, 831e836. Charpak, N., Gabriel Ruiz-Pela ´ez, J., 2006. Resistance to implementing Kangaroo Mother Care in developing countries, and proposed solutions. Acta Paediatrica 95, 529e534. Chia, P., Sellick, K., Gan, S., 2006. The attitudes and practices of neonatal nurses in the use of kangaroo care. Australian Journal of Advanced Nursing 23, 20e27.
L. Valizadeh et al. Conde-Agudelo, A., Beliza ´n, J.M., Diaz-Rossello, J., 2011. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 16. Cong, X., Ludington-Hoe, S.M., Walsh, S., 2011. Randomized crossover trial of kangaroo care to reduce biobehavioral pain responses in preterm infants: a pilot study. Biological Research for Nursing 13, 204. Ferber, S.G., Makhoul, I.R., 2004. The effect of skin-to-skin contact (kangaroo care) shortly after birth on the neurobehavioral responses of the term newborn: a randomized, controlled trial. Pediatrics 113, 858. Franklin, C., 2006. The neonatal nurse’s role in parental attachment in the NICU. Critical Care Nursing Quarterly 29, 81. Gathwala, G., Singh, B., Balhara, B., 2008. KMC facilitates mother baby attachment in low birth weight infants. Indian Journal of Pediatrics 75, 43e47. Harrison N, L.L.A.W., Woods, S., 1991. Early parental touch and preterm infants. Journal of Obstetric, Gynecologic, & Neonatal Nursing 20, 299e306. Hunt, F., 2008. The importance of kangaroo care on infant oxygen saturation levels and bonding. Journal of Neonatal Nursing 14, 47e51. Johnson, A.N., 2005. Kangaroo holding beyond the NICU. Pediatric Nursing 31, 53. Johnson, A.N., 2008. Promoting maternal confidence in the NICU. Journal of Pediatric Health Care 22, 254e257. Johnston, C.C., Stevens, B., Pinelli, J., Gibbins, S., Filion, F., Jack, A., Steele, S., Boyer, K., Veilleux, A., 2003. Kangaroo care is effective in diminishing pain response in preterm neonates. Archives of Pediatrics and Adolescent Medicine 157, 1084. Karabel, M., Tan, S., Tatli, M.M., Yilmaz, A.E., Tonbul, A., Karadag, A., 2011. Separation anxiety disorder increases among neonatal intensive care unit graduates. Journal of Maternal-Fetal and Neonatal Medicine, 1e6. Kearvell, H., Grant, J., 2010. Getting connected: how nurses can support mother/infant attachment in the neonatal intensive care unit. Australian Journal of Advanced Nursing 27, 75. Kenner, C., McGrath, J., 2004. In: Kenner, C., McGrath, J.M. (Eds.), Developmental Care of Newborns & Infants. Mosby Ed., St Louis MO 63123. Kulkarni, A., Kaushik, J.S., Gupta, P., Sharma, H., Agrawal, R., 2010. Massage and touch therapy in neonates: the current evidence. Indian Pediatrics 47, 771e776. Ludington-Hoe, S.M., Cranston Anderson, G., Simpson, S., Hollingsead, A., Argote, L.A., Rey, H., 1999. Birthrelated fatigue in 34e36-week preterm neonates: rapid recovery with very early kangaroo (skin-to-skin) care. Journal of Obstetric, Gynecologic, & Neonatal Nursing 28, 94e103. McCord, H., 2011. Exploring Nurses’ Perceptions on the Use of Kangaroo Mother Care to Reduce Pain During Heel Lance Procedures. Mori, R., Khanna, R., Pledge, D., Nakayama, T., 2010. Metaanalysis of physiological effects of skin-to-skin contact for newborns and mothers. Pediatrics International 52, 161e170. Nyqvist, K.H., Engvall, G., 2009. Parents as their infant’s primary caregivers in a neonatal intensive care unit. Journal of Pediatric Nursing 24, 153e163. Parisi, T.C.H., Coelho, E.R.B., Melleiro, M.M., 2008. Implantation of the Kangaroo Mother Method in the perception of nurses in a university hospital. Acta Paulista de Enfermagem 21, 575e580.
Impact of Kangaroo Mother Care
43
Parmar, V.R., Kumar, A., Kaur, R., Parmar, S., Kaur, D., Basu, S., Jain, S., Narula, S., 2009. Experience with Kangaroo mother care in a neonatal intensive care unit (NICU) in Chandigarh, India. Indian Journal of Pediatrics 76, 25e28. Ramanathan, K., Paul, V., Deorari, A., Taneja, U., George, G., 2001. Kangaroo mother care in very low birth weight infants. Indian Journal of Pediatrics 68, 1019e1023. Settle, M., Williams, D., Engler, A.J., Ludington-Hoe, S.M., Cusson, R.M., Adams, R., Bahnsen, M., Brumbaugh, E., Coates, P., Grieb, J., 2002. Kangaroo care: national survey of practice, knowledge, barriers, and perceptions. MCN: The American Journal of Maternal/Child Nursing 27, 146.
Solimani, F., SolIran, F., 2007. Developmental outcome of LBW and premature Infants. Iran Journal of Pediatrics (Persian) 17, 133. Tessier, R., Cristo, M.B., Velez, S., Giron, M., Nadeau, L., Figueroa de Calume, Z., Ruiz-Pal˛i ez, J.G., Charpak, N., 2003. Kangaroo mother care: a method for protecting high-risk lowbirth-weight and premature infants against developmental delay. Infant Behavior and Development 26, 384e397. Tilokskulchai, F., Phatthanasiriwethin, S., Vichitsukon, K., Serisathien, Y., 2002. Attachment behaviour in mothers of premature infants: a descriptive study in Thai mothers. The Journal of Perinatal & Neonatal Nursing 16, 69.
Available online at www.sciencedirect.com
www.elsevier.com/jneo
Nurses’ viewpoint about the impact of Kangaroo Mother Care on the mothereinfant attachment Leila Valizadeh a,1,2, Najmeh Ajoodaniyan a,1,2, Mahboobeh Namnabati a,*,2, Vahid Zamanzadeh b,1,2, Vahideh layegh c,2 a
Department of Child and Family Health, Tabriz University of Medical Sciences, Tabriz, Iran Medical and Surgical Department, Tabriz University of Medical Sciences, Tabriz, Iran c Al-Zahra Hospital, Tabriz University of Medical Sciences, Tabriz, Iran b
Available online 9 June 2012
KEYWORDS Kangaroo Mother Care; Attachment; NICU; Viewpoint
Abstract Aim: The aim of this investigation was to determine nurses’ viewpoint about the impact of Kangaroo Mother Care on the attachment between mother and infant. Methods: A descriptive study was carried out with the staff (23 nurses) of an NICU of a University Hospital in Iran. Data were collected through self-report method (Avant Maternal Attachment Behavior Scale) and analyzed by use of SPSS. Findings: The majority of the participants had positive viewpoint on the subject of study. The affectionate behavioral subscale had the most effect on the mothereinfant attachment, while the item “holding without skin contact” of proximity maintaining subscale was looked at as the most disagree and strongly disagree item (68.2%) of the attachment scale. Conclusion: According to the nurses’ viewpoints, mothereinfant attachment behavior are strengthened by applying the Kangaroo Mother Care. Furthermore, the benefits of this type of care are mentioned. ª 2012 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ98 311 6688965. E-mail addresses: [email protected] (L. Valizadeh), [email protected] (N. Ajoodaniyan), [email protected] (M. Namnabati), [email protected] (V. Zamanzadeh), [email protected] (V. layegh). 1 Tel.: þ98 411 4796770. 2 All authors were involved in study for design, data collection, analysis, drafting of manuscript, critical revisions, and statistical expertise. 1355-1841/$ - see front matter ª 2012 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jnn.2012.05.004
Impact of Kangaroo Mother Care
Introduction Attachment is a unique relationship between the parents and the infant (Kenner and McGrath, 2004). It begins in prenatal period when the fetus grows inside mother’s body; and after the birth when the mother gradually recognizes infant’s cues, adapts to his/her behavior, and tries to meet the needs of her infant (Johnson, 2008). This reciprocity parentseinfant relationship, as an essential element of the attachment process, helps satisfying both the mother and the infant (Kenner and McGrath, 2004). Kangaroo Mother Care (KMC) facilitates the process as more convenient as possible (Gathwala et al., 2008). Studies indicate that the advantages of skin-toskin contact can cause infant’s physiologic stability such as regulating body temperature, improving oxygen saturation levels, and reducing apnea (Cong et al., 2011). It improves the exclusive breastfeeding period which results in more milk production and weight gained, and earlier discharge of mother and infant (Hunt, 2008; Johnston et al., 2003). KMC also can help reducing infant’s response to pain and childhood behavioral problems (Bohnhorst et al., 2001; Ludington-Hoe et al., 1999; Mori et al., 2010). Despite the above and many other advantages of the KMC, there are some barriers with its application such as safety, staff reluctance and shortage, insufficient education, lack of organizational support, and the absence of pertinent protocols which prevent enforcing the care in the NICU (Chia et al., 2006). Hospitalization may also delay the attachment and impede the mothereinfant relationship. To solve the problem, KMC can establish the attachment by physical contact between the preterm newborn and the mother in the NICU (Franklin, 2006; Johnson, 2008; Karabel et al., 2011). Consequently, it strengthens the quality of the parenteinfant relationship psychologically, socially, and emotionally and also affects the long-term outcome of growth and development. On the contrary, it should be tangibly noted that the attachment disorder, as a product of maternal separation or lack of mother care may lead in complications such as failure to thrive, separation anxiety disorder, personality disorder, school problems, crime and so on (Karabel et al., 2011; Ludington-Hoe et al., 1999). It was estimated that 9.6% of all births worldwide were preterm. Approximately 85% of these preterm births were concentrated in Africa and Asia (Beck et al., January 2010). According to the reports of medical sciences universities in Iran,
39 7.2% of total births were preterm (Solimani and SolIran, 2007). Two-third of all neonatal deaths occurred in low birth weight. KMC was found to reduce morbidity and mortality in low birth weight infants (Conde-Agudelo et al., 2011). Nurse plays a crucial role in the care of infant and helps the mother to promote her attachment behavior with the infant in the NICU (Johnson, 2008). Their mothers were instructed for applying KMC. KMC has been being applied since 2005 in the only equipped high-tech NICU of a University Hospital in NortheWest of Iran. Authorities have planned to apply the KMC through some workshops, to be held for all nurses working there. The focus has been made on the effects of KMC on neonates in pervious studies (Boo and Jamli, 2007; Parmar et al., 2009; Tessier et al., 2003). But no investigation has been done about the staff’s attitude toward the effect of this procedure on the attachment in Iran. Researchers believe that the nurse’s attitude can affect her performance and collaboration with the mother in using KMC. The purpose of this study was to determine nurses’ viewpoint about the impact of applying KMC on mothereinfant attachment in the NICU.
Methods Participants and setting A descriptive study was conducted in a university hospital in Tabriz, Iran in 2010. All 23 invited nurses were the staff of the unit. They had already worked in three levels of the NICU for six months or more and had performed KMC for at least ten times.
Instrument Data were collected by use of a two-part questionnaire. The first part included demographic information of participants such as age, sex, work experience and etc. The second part was a modified Avant Maternal Attachment Behavior Scale to assess the mothereinfant attachment. It consists of self-report questionnaire of 13 items on 5-point Likert-type scales ranging from 1 (strongly disagree) to 5 (strongly agree). It was divided into three subscales: A) the affectionate behavior (looking, kissing, talking, smiling, rocking, touching, and full attention), B) the proximity maintaining subscale (holding without skin contact, encompassing in both arms and close contact), and C) the caretaking behavior (diaper
40
L. Valizadeh et al.
changing, burping, and undressing). Also, a general question was asked about KMC and its effects. All nurses completed and returned the questionnaires. Translation accuracy of the attachment scale was considered. Cronbach’s alpha was used to determine the reliability and examine the correlation between the items of the scale and it was 0.7.
Data analysis and ethical issues Data analysis was performed with the SPSS, version 17. Descriptive statistics such as frequency, percentage, mean, and standard deviation were calculated and Freidman test was carried out too as a non-parametric test. Permission to conduct the study was obtained from the ethics committee of the Tabriz University of Medical sciences and a written consent was taken from every participant.
Findings All of the participants were NICU nurse employees and had worked in all shifts in turnover. All of them (100%) had learned the principals of KMC through continuing education and had repeatedly performed it as a task. They had clinical experience in all shifts for at least six months to maximum 12 years (Table 1). There were three subscales in the modified Avant Maternal Attachment Behavior Scale which measured nurses’ viewpoints about the effects of KMC on the attachment. Findings revealed a positive viewpoint in all subscales (M ¼ 4.08 0.36). Freidman test showed that affection behavior subscale had the most positive viewpoint among the other three subscales (Mean rank ¼ 2.61). It
Table1
Demographic variables of nurses.
Characteristics of parents
Number
(%)
Mean (year)
SD
Sex (Female) Age Clinical experience Marital status Married Single Having children Yes No Graduation state Bachelor Nursing diploma
23 23 23
(100) (100) (100)
e 32.8 6.5
e 5.3 2.6
18 5
(78.3) (21.7)
e e
e e
17 6
(74) (26)
e e
e e
22 1
(95) (5)
e e
e e
was widely believed that KMC had a major impact on the affectionate behavior and touching was viewed to have 100% agreement by nurses. The caretaking behavior subscale was thought to have the least effect among these subscales and burping among the other items had the weakest agreement from the nurses (26.1%). The item “encompassing in both arms” had the most agreement from the nurses (95%) in the proximity maintaining subscale. Nurses were agreed and even strongly agreed with more than 75% of items such as encompassing in both arms, smiling, undressing, and kissing respectively. Interestingly, it was reported that the majority of nurses (68.2%) were disagreed and strongly disagreed with holding without skin contact by the mother. Touching, encompassing in both arms, and undressing took an overall score of more than 90% of agreement and strongly agreement of the nurses in the three subscales in the modified Avant Maternal Attachment Behavior Scale (Table 2). As an answer to one general question, all participants mentioned a variety of beneficial effects of applying KMC in NICU since 2005. The 90% of the responses showed an increase in mother’s affection, better mothereneonate relationship, mother’s presence in the unit, consoling neonate, calming mother, involvement in neonate’s care such as bathing and feeding.
Discussion This study clarified a comprehensive picture of neonatal nurses’ viewpoint about the impact of applying KMC on the attachment behavioral scale in recent years. The majority of nurses had positive view toward the most items of attachment scales. Similarly, studies reported that the majority of nurses had positive attitudes to the use of KMC (Chia et al., 2006; McCord, 2011; Settle et al., 2002) and mothers had a significantly higher attachment score in the KMC group than mothers in control group (Gathwala et al., 2008). Thus, positive attitude could have led to strong support of applying KMC as a daily routine care (Ramanathan et al., 2001). According to the nurses’ viewpoint, 12 of 13 items were strengthened after applying KMC. Touching was considered as the most important item in the attachment scale. In a review study, it was shown that the positive effects of touch improve emotional bonding and physiologic stability such as thermoregulation, gaining weight, better sleep-wake pattern, enhanced neuromotor development (Kulkarni et al., 2010). KMC, a model
Impact of Kangaroo Mother Care Table 2
41
Frequency distribution nurses’ viewpoint of impact of KMC on mothereinfant attachment.
Items A. Affectionate behaviors Looking Touching Kissing Talking Smiling Rocking Full attention B. Proximity maintaining Holding without skin contact Encompassing in both arms Close contact C. The caretaking behaviors Diaper changing Burping Undressing
Strongly agree (%)
Agree (%)
Do not know (%)
Disagree (%)
Strongly disagree (%)
Mean SD (%)
87 91.3 39.1 78.3 82.6 18.2 30
8.7 8.7 34.8 17.4 8.7 36.4 35
4.3 e 8.7 4.3 8.7 22.7 15
e e 13 e e 18.2 20
e e 4.3 e e 4.5 e
4.78 4.89 3.84 4.78 4.78 3.42 3.73
9.1
9.1
13.6
40.9
27.3
2.31 1.24
59.1 59.1
36.4 36.4
4.5 4.5
e e
e e
3.90 0.97 4.54 0.59
39.1 26.1 31.8
30.4 39.1 59.1
17.4 13 9.1
13 5 e
e e e
4.04 0.99 3.68 1.12 4.22 0.61
of care, regulates nerve system that leads to decreased stress for both mother and infant (Ferber and Makhoul, 2004). This interventional care can motivate the mother to be a more passionate and enthusiastic mother (Harrison N and Woods, 1991; Johnson, 2005). In some NICUs, mothers are encouraged to use Kangaroo Care to have skin contact, not only to just warm but rather to stimulate touching, smelling, hearing, and feeling closer to the baby as well (Franklin, 2006). A survey showed that a 15e20 min skin contact made the mother the fortune to have time for kissing and looking at her baby. Another study confirmed that using KMC, mothers had more verbal and nonverbal behavior such as laughing, hugging, and checking the baby (Tilokskulchai et al., 2002). In current study, the majority of the participants disagreed with the item "holding without skin contact". It seems that the nurses couldn’t imagine KMC without skin-to-skin contact. In general, in respond to the question about the effects of KMC, nurses counted several benefits of the care such as increasing maternal affection and involving the mother in taking care of the baby. Personnel were instructed to emphasize on the presence of mothers at the unit for applying KMC. Consequently, they were to take care of their babies unwillingly in much of their day time. Studies confirmed that being in the NICU around the clock and having the role of a partner, the mother can improve attachment and caring and expedite the discharge from NICU (Bakewell-Sachs and Gennaro, 2004; Nyqvist and Engvall, 2009).
0.53 0.31 1.16 0.41 0.53 1.21 1.14
Despite increasing evidence for benefits of KMC, some studies have indicated barriers to applying KMC such as lack of policies for KMC implementation and insufficient academic integration. The implementation barriers and understanding the circumstances of KMC were identified in 25 developing countries. The researchers presented several themes which caregivers express as negative aspects of KMC including: discomfort in placing the infant on the bare chest, a perceived lack of privacy, difficulty in maintaining thermal control, and cultural differences related to diapering (Charpak and Gabriel Ruiz-Pela ´ez, 2006; Settle et al., 2002). In addition, it needs more staff, sufficient education, and organizational support, especially for low birth weight infants (Chia et al., 2006). Knowing that their attitude and role can affect parents’ tends to perform KMC, NICU nurses teach the parents the KMC method as a daily task (Blomqvist et al., 2011). In fact, their positive and realistic attitude support parents and ease the early attachment (Kearvell and Grant, 2010). Nurses play a unique role in improving mothereinfant interaction through KMC in order to encourage breastfeeding and participation in routine care. Alongside, the psychosocial support and the effective, communication established in motherenurse interaction, are vital in connections between the mother and her infant (Parisi et al., 2008). The small sample size was a limitation to the study. However, with regards to increased use of KMC in the recent years in Iran, it was worth to
42 assess the attitude of nurses. It is suggested to explore the feasibility, obstacles and solutions to the application of KMC for under ventilated preterm infants in the next study. The impact of KMC could also be of worth to evaluate the attachment between the father and the infant in our culture. On account of knowing little about the long-term outcomes of KMC, it is also recommended to perform a research about the outcomes of KMC based on the different context or culture.
Conclusion The result of this study confirms that the nurses had a strong positive viewpoint on the use of KMC in NICU. All of them mentioned that mothers and infants have taken benefits of KMC since it has been applied in the NICU in Iran. Interestingly, the affection behavioral subscale was the important aspect which affects the attachment. Nurses believed that this method of caring supports developmental care, and improves the attachment between mother and infant.
Acknowledgments With thanks to the cooperation of research bureau of Tabriz University of Medical Science and AlZahra Hospital. The authors would like to thank the nurses who participated in this study.
References Bakewell-Sachs, S., Gennaro, S., 2004. Parenting the post-NICU premature infant. MCN: The American Journal of Maternal/ Child Nursing 29, 398. Beck, S., Wojdyla, D., Say, L., Betran, A., Mario, M., Requejo, J., Rubens, C., Menon, R., V.L, P., January 2010. The Worldwide Incidence of Preterm Birth: a Systematic Review of Maternal Mortality and Morbidity, pp. 1e80. Blomqvist, Y.T., Rubertsson, C., Frolund, L., Nyqvist, K.H., 2011. Provision of Kangaroo Mother Care: Facilators and Barriers Neo-BFHI. Uppsala Universitet, Uppsala, Sweden, p. 27. Bohnhorst, B., Heyne, T., Peter, C.S., Poets, C.F., 2001. Skin-toskin (kangaroo) care, respiratory control, and thermoregulation. Journal of Pediatrics 138, 193e197. Boo, N.Y., Jamli, F.M., 2007. Short duration of skin-to-skin contact: effects on growth and breastfeeding. Journal of Paediatrics and Child Health 43, 831e836. Charpak, N., Gabriel Ruiz-Pela ´ez, J., 2006. Resistance to implementing Kangaroo Mother Care in developing countries, and proposed solutions. Acta Paediatrica 95, 529e534. Chia, P., Sellick, K., Gan, S., 2006. The attitudes and practices of neonatal nurses in the use of kangaroo care. Australian Journal of Advanced Nursing 23, 20e27.
L. Valizadeh et al. Conde-Agudelo, A., Beliza ´n, J.M., Diaz-Rossello, J., 2011. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 16. Cong, X., Ludington-Hoe, S.M., Walsh, S., 2011. Randomized crossover trial of kangaroo care to reduce biobehavioral pain responses in preterm infants: a pilot study. Biological Research for Nursing 13, 204. Ferber, S.G., Makhoul, I.R., 2004. The effect of skin-to-skin contact (kangaroo care) shortly after birth on the neurobehavioral responses of the term newborn: a randomized, controlled trial. Pediatrics 113, 858. Franklin, C., 2006. The neonatal nurse’s role in parental attachment in the NICU. Critical Care Nursing Quarterly 29, 81. Gathwala, G., Singh, B., Balhara, B., 2008. KMC facilitates mother baby attachment in low birth weight infants. Indian Journal of Pediatrics 75, 43e47. Harrison N, L.L.A.W., Woods, S., 1991. Early parental touch and preterm infants. Journal of Obstetric, Gynecologic, & Neonatal Nursing 20, 299e306. Hunt, F., 2008. The importance of kangaroo care on infant oxygen saturation levels and bonding. Journal of Neonatal Nursing 14, 47e51. Johnson, A.N., 2005. Kangaroo holding beyond the NICU. Pediatric Nursing 31, 53. Johnson, A.N., 2008. Promoting maternal confidence in the NICU. Journal of Pediatric Health Care 22, 254e257. Johnston, C.C., Stevens, B., Pinelli, J., Gibbins, S., Filion, F., Jack, A., Steele, S., Boyer, K., Veilleux, A., 2003. Kangaroo care is effective in diminishing pain response in preterm neonates. Archives of Pediatrics and Adolescent Medicine 157, 1084. Karabel, M., Tan, S., Tatli, M.M., Yilmaz, A.E., Tonbul, A., Karadag, A., 2011. Separation anxiety disorder increases among neonatal intensive care unit graduates. Journal of Maternal-Fetal and Neonatal Medicine, 1e6. Kearvell, H., Grant, J., 2010. Getting connected: how nurses can support mother/infant attachment in the neonatal intensive care unit. Australian Journal of Advanced Nursing 27, 75. Kenner, C., McGrath, J., 2004. In: Kenner, C., McGrath, J.M. (Eds.), Developmental Care of Newborns & Infants. Mosby Ed., St Louis MO 63123. Kulkarni, A., Kaushik, J.S., Gupta, P., Sharma, H., Agrawal, R., 2010. Massage and touch therapy in neonates: the current evidence. Indian Pediatrics 47, 771e776. Ludington-Hoe, S.M., Cranston Anderson, G., Simpson, S., Hollingsead, A., Argote, L.A., Rey, H., 1999. Birthrelated fatigue in 34e36-week preterm neonates: rapid recovery with very early kangaroo (skin-to-skin) care. Journal of Obstetric, Gynecologic, & Neonatal Nursing 28, 94e103. McCord, H., 2011. Exploring Nurses’ Perceptions on the Use of Kangaroo Mother Care to Reduce Pain During Heel Lance Procedures. Mori, R., Khanna, R., Pledge, D., Nakayama, T., 2010. Metaanalysis of physiological effects of skin-to-skin contact for newborns and mothers. Pediatrics International 52, 161e170. Nyqvist, K.H., Engvall, G., 2009. Parents as their infant’s primary caregivers in a neonatal intensive care unit. Journal of Pediatric Nursing 24, 153e163. Parisi, T.C.H., Coelho, E.R.B., Melleiro, M.M., 2008. Implantation of the Kangaroo Mother Method in the perception of nurses in a university hospital. Acta Paulista de Enfermagem 21, 575e580.
Impact of Kangaroo Mother Care
43
Parmar, V.R., Kumar, A., Kaur, R., Parmar, S., Kaur, D., Basu, S., Jain, S., Narula, S., 2009. Experience with Kangaroo mother care in a neonatal intensive care unit (NICU) in Chandigarh, India. Indian Journal of Pediatrics 76, 25e28. Ramanathan, K., Paul, V., Deorari, A., Taneja, U., George, G., 2001. Kangaroo mother care in very low birth weight infants. Indian Journal of Pediatrics 68, 1019e1023. Settle, M., Williams, D., Engler, A.J., Ludington-Hoe, S.M., Cusson, R.M., Adams, R., Bahnsen, M., Brumbaugh, E., Coates, P., Grieb, J., 2002. Kangaroo care: national survey of practice, knowledge, barriers, and perceptions. MCN: The American Journal of Maternal/Child Nursing 27, 146.
Solimani, F., SolIran, F., 2007. Developmental outcome of LBW and premature Infants. Iran Journal of Pediatrics (Persian) 17, 133. Tessier, R., Cristo, M.B., Velez, S., Giron, M., Nadeau, L., Figueroa de Calume, Z., Ruiz-Pal˛i ez, J.G., Charpak, N., 2003. Kangaroo mother care: a method for protecting high-risk lowbirth-weight and premature infants against developmental delay. Infant Behavior and Development 26, 384e397. Tilokskulchai, F., Phatthanasiriwethin, S., Vichitsukon, K., Serisathien, Y., 2002. Attachment behaviour in mothers of premature infants: a descriptive study in Thai mothers. The Journal of Perinatal & Neonatal Nursing 16, 69.
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