A Meta-ethnography: Skin-to-Skin Holding From the Caregiver's Perspective

Parents' and healthcare providers' perceptions, experiences, knowledge of, and attitudes toward kangaroo care of preterm babies in hospital settings: Mixed-methods systematic review

BACKGROUND

Kangaroo care is an effective intervention to increase survival and improve the health and development of preterm infants. Despite this, implementation of kangaroo care globally remains low. The objectives of this review were to: (a) synthesize evidence on parents' and healthcare practitioners' perceptions, experiences, knowledge of, and attitudes toward kangaroo care of preterm babies in hospital settings; and (b) establish parents' satisfaction with kangaroo care.

METHODS

Studies of any design were included if they focused on parents' or healthcare practitioners' perceptions, experiences, knowledge of, and attitudes to kangaroo care of preterm babies, or reported parents' satisfaction, and were conducted in hospital settings. The search of seven electronic databases, African Journals Online, World Health Organization regional databases, and a gray literature search was conducted in April/May 2020, and updated in January 2024. Study selection was undertaken by two independent reviewers. Quality assessment using the Mixed Method Appraisal Tool and data extraction were completed by one reviewer with a 10% check by a second reviewer. Data were synthesized narratively using a parallel results convergent integrated design.

RESULTS

Thirty-seven studies, 19 quantitative, 16 qualitative, and 2 mixed methods, were included. The findings suggested that while healthcare practitioners generally demonstrated knowledge about kangaroo care, there was a notable minority with insufficient understanding among those who received training. Parents' knowledge, particularly among fathers, was limited. Both healthcare practitioners and parents appeared to have positive attitudes to kangaroo care. Little is known about parental satisfaction with kangaroo care.

CONCLUSIONS

Most healthcare practitioners were knowledgeable about kangaroo care, but parents had limited knowledge. This review findings suggest a need to enhance parental knowledge of kangaroo care before neonatal unit admission, and training is needed for HCPs to implement kangaroo care consistently.

Parental perceptions and experiences of kangaroo care for preterm infants in neonatal intensive care units in China: a qualitative study

BACKGROUND

kangaroo care (KC), endorsed by the World Health Organization, is an evidence-based intervention that plays a pivotal role in mitigating preterm infant mortality and morbidity. However, this intervention has not been fully integrated into healthcare systems in China. This study aimed to gain insight into parents' perceptions and experiences of KC for preterm infants to contribute to the KC implementation on a larger scale.

METHODS

This study employed a descriptive qualitative design, using face-to-face, semi-structured, in-depth interviews. Fifteen parents participating in KC for preterm infants in the neonatal intensive care units (NICUs) were purposively sampled from four hospitals across four cities in Zhejiang Province, China. Thematic analysis was employed to analyze the data.

RESULTS

Four themes and twelve subthemes regarding the parents' perceptions and experiences about KC were identified. The four themes included: (1) Low motivation upon initial engagement with KC, (2) Dynamic fluctuations of emotional states during KC, (3) Unexpected gains, and (4) Barriers to participation.

CONCLUSIONS

Parents' perceptions and experiences of KC was a staged process, with parents exhibiting distinct cognitive patterns and unique experiences at each stage. Overall, as KC progresses, parents' experiences tended to become increasingly positive, despite potential obstacles encountered along the way. To enhance the implementation of KC, healthcare providers could utilize prenatal and postnatal education programs. These programs aim to enhance the understanding of KC among parents of preterm infants, fostering sustained engagement in KC practices.

Healthcare providers' perceptions and experiences of kangaroo mother care for preterm infants in four neonatal intensive care units in China: a qualitative descriptive study

Background

Kangaroo mother care (KMC) is an evidence-based intervention that can effectively reduce morbidity and mortality in preterm infants, but it has yet to be widely implemented in health systems in China. Most qualitative studies on KMC for preterm infants focused on the experiences and influencing factors from the perspective of preterm infant parents, while neglecting the perspective of healthcare providers, who played a critical role in guiding KMC practice. Therefore, this study aimed to explore the perceptions and experiences of healthcare providers regarding their involvement in KMC implementation for preterm infants to promote the contextualized implementation of KMC.

Methods

A descriptive qualitative approach was adopted. A purposive sampling was used to select healthcare providers involved in KMC implementation in the neonatal intensive care units (NICUs) as participants from four tertiary hospitals across four cities in Zhejiang Province, China. Face-to-face semi-structured interviews were conducted to collect information. Thematic analysis was employed to analyze the data.

Results

Seventeen healthcare professionals were recruited, including thirteen nurses and four doctors in the NICUs. Four themes and twelve subthemes emerged: different cognitions based on different perspectives (acknowledged effects and benefits, not profitable economically), ambivalent emotions regarding KMC implementation (gaining understanding, gratitude and trust from parents, not used to working under parental presence, and concerning nursing safety issues), barriers to KMC implementation (lack of unified norms and standards, lack of systematic training and communication platform, insufficient human resources, and inadequate parental compliance) and suggestions for KMC implementation (improving equipment and environment, strengthening collaboration between nurses and doctors, and support from hospital managers).

Conclusions

Despite acknowledging the clinical benefits of KMC, the lack of economic incentives, concerns about potential risks, and various barriers hindered healthcare providers' intrinsic motivation to implement KMC in NICUs in China. To facilitate the effective implementation of KMC, hospital managers should provide bonuses and training programs for healthcare providers, while giving them recognition and encouragement to enhance their motivation to implement KMC.

Release of Oxytocin and Cortisol Is Associated With Neurobehavioral Patterns in Premature Infants

OBJECTIVE

To examine relationships among salivary oxytocin and cortisol levels in parents and preterm infants and neurobehavioral functioning in preterm infants after skin-to-skin contact.

DESIGN

A secondary analysis of a randomized crossover study.

SETTING

NICU.

PARTICIPANTS

Twenty-eight stable premature infants and their mothers and fathers.

METHODS

Participating infants contributed 108 saliva samples that we collected 45 minutes after skin-to-skin contact and tested for oxytocin and cortisol. We randomized data collection by whether the infant was held first by the mother or by the father. We conducted linear regression to test if summary scores on the NICU Network Neurobehavioral Scale were associated with salivary oxytocin and cortisol levels.

RESULTS

We found a significant negative relationship between infant oxytocin levels and the Stress scores (b = -0.07, p < .01) and the Excitability scores (b = -1.12, p = .04) among infants held skin-to-skin with their mothers. We found a significant positive relationship between infant oxytocin levels and the Self-Regulatory scores (b = 0.38, p = .05) among infants held skin-to-skin with their mothers. We found a significant positive relationship between infant cortisol level and the Stress scores (b = 0.05, p = .04), Excitability scores (b = 1.06, p = 0.05), and Asymmetrical Reflexes scores (b = 1.21, p = .03) among infants held skin-to-skin with their mothers. We only found a negative significant relationship between infant cortisol levels and the Stress scores (b = -0.03, p = .04) among infants held skin-to-skin with their fathers.

CONCLUSION

We found that oxytocin is an important biomarker that may improve infant neurobehavioral functioning. The data showed a difference in oxytocin responses after skin-to-skin contact with mothers compared to fathers.

Early Skin-to-Skin Contact in Preterm Infants: Is It Safe? An Italian Experience

BACKGROUND

Skin-to-skin contact (SSC) is one of the four components of kangaroo care (KC) and is also a valued alternative to incubators in low-income countries. SSC has also become a standard of care in high-income countries because of its short- and long-term benefits and its positive effect on infant growth and neurodevelopmental outcome. However, barriers in the implementation of SSC, especially with preterm infants, are common in NICUs because parents and health care professionals can perceive it as potentially risky for the clinical stability of preterm infants. Previous studies have assessed safety before and during SSC by monitoring vital parameters during short-time intervals.

AIMS

To demonstrate the safety of early SSC in preterm infants during at least 90 min intervals.

DESIGN

Prospective observational monocentric study.

METHODS

Preterm infants born between June 2018 and June 2020 with a gestational age of ≤33 weeks and a birth weight of <2000 g were monitored while performing an SSC session during the first three weeks of life. Infants with necrotizing enterocolitis, sepsis, and congenital malformations on mechanical ventilation or with more than five apneas in the hour before SSC were excluded. Continuous oxygen saturation (SaO2), heart rate (HR), and respiratory rate (RR) were registered during an SSC session and in the hour before. The minimum duration of an SSC session was 90 min. Information regarding postmenstrual age (PMA), body weight, respiratory support, presence of a central venous catheter and the onset of sepsis within 72 h after a session was collected. Two physicians, blinded to infant conditions and the period of analysis (before or during SSC), evaluated desaturation episodes (SaO2 < 85%, >15 s), bradycardia (HR < 100, >15 s) and apneas (pause in breathing > 20 s associated with desaturation and/or bradycardia). A Wilcoxon rank sum test was used for the statistical analysis.

RESULTS

In total, 83 episodes of SSC were analyzed for a total of 38 infants. The mean gestational age at birth was 29 weeks (range 23-33 weeks). Median PMA, days of life, and body weight at SSC were 31 weeks (range 25-34 weeks), 10 days (range 1-20 days), and 1131 g (range 631-2206 g), respectively. We found that 77% of infants were on respiratory support and 47% of them had a central venous catheter (umbilical or peripherally inserted central catheter) during SSC. The total duration of desaturation, bradycardia, and the number of apneas were not statistically different during the SSC session and the hour before. No catheter dislocation or ruptures were reported.

CONCLUSIONS

These findings highlighted the safety of early SSC in preterm infants and the possibility of performing it in an intensive care setting in the first weeks of life. In addition, these findings should reassure health care professionals offering this practice as a standard of care. SSC plays a key role in the care of preterm infants due to its short- and long-term positive benefits, and it deserves to be increasingly offered to infants and their parents.

French translation and preliminary psychometric validation of a skin-to-skin contact instrument for nurses (SSC-F)

PURPOSE

To translate and conduct the preliminary psychometric validation of a skin-to-skin contact instrument in French (SSC-F) with a sample of nurses from Quebec and France working in neonatal intensive care units.

METHODS

The 20 items of the SSC instrument containing four subscales (knowledge, attitudes and beliefs, training and education and implementation), developed by Vittner et al. (2017), was translated into French. The methodological steps used for psychometric validation included assessment of the item and subscale normality distributions, assessment of reliability using internal consistency, and assessment of validity using inter-item and inter-scale correlations and principal component analysis.

RESULTS

The preliminary psychometric validation showed that all four subscales of the French version had adequate internal consistency (0.61-0.77), supporting the calculation of a total score for each subscale based on the English version of the instrument. The structural validity was supported by principal component analysis findings.

PRACTICE IMPLICATIONS

Based on the findings of the preliminary psychometric validation of our study, the SSC-F instrument could be used in research with French-speaking neonatal nurses in Western countries, but gathering more evidence about its reliability and validity is warranted for clinical practice.

A Survey of Neonatal Clinicians' Use, Needs, and Preferences for Kangaroo Care Devices

BACKGROUND

Decades of research supports the benefits of kangaroo care (KC) for the parent and newborn. Supportive KC devices may be an important tool clinicians can use to assist parents with KC. In recent years, there has been a rise in the availability of KC devices. However, the use, needs, and preferences for these supportive devices by neonatal clinicians have not been documented.

PURPOSE

To survey clinicians' use, needs, and preferences of KC supportive devices, and examine whether differences exist based on clinician and organizational characteristics.

METHODS

A cross-sectional, online survey was sent through neonatal organization Web sites, conferences, and social media.

RESULTS

Many clinicians (n = 68, 43%; N = 158) facilitated KC with a supportive device, with 81% of devices provided by the clinician's employer. The most important "Must Have" feature of a KC device was "Safety: Reduces patient falls if caregiver sleeps or needs to use hands" (84% of respondents) followed by washability (82%), and "immediate, effective access to the baby" (78%). Clinicians' responses did not differ based on hospital setting, type of unit, KC experience, or experience using a KC device.

IMPLICATIONS FOR PRACTICE

To support safe use of KC devices in neonatal intensive care unit (NICU) clinical care, a device must hold the proper KC position consistently, allow immediate access to the infant, and hold the infant in place without the parent's hands to prevent falls. Training is needed to ensure safe device use.

IMPLICATIONS FOR RESEARCH

Future research should evaluate the safety, efficacy, and cost-effectiveness of these devices.

Implementing a Skin-to-Skin Care and Parent Touch Initiative in a Tertiary Cardiac and Surgical Neonatal Intensive Care Unit

BACKGROUND

Skin-to-skin care (SSC) has been integrated as an essential component of developmental care for preterm infants. Despite documented benefits, SSC is not routinely practiced in the cardiac and surgical neonatal intensive care unit, with a predominantly term population, due to staff apprehension, patient factors and acuity, and environmental constraints.

PURPOSE

The purpose of this quality improvement project was to increase SSC, parental holds, and parent touch events for infants in our cardiac and surgical neonatal intensive care unit. When traditional SSC was not possible, alternative holds and alternative parent touch (APT) methods were encouraged.

METHODS

Quality improvement and qualitative descriptive methodology were utilized to assess baseline, develop education and practice changes, and evaluate the use of SSC, holds, and APT methods at 12 and 18 months postintervention. Implementation included educational tools and resource development, simulations, peer champions, in-class teaching, and team huddles. Decisions around the type of hold and parent touch were fluid and reflected complex infant, family, staff, and physical space needs.

FINDINGS

Given its initial scarcity, there was an increased frequency of SSC and variety of holds or APT events. Staff survey results indicated support for the practice and outlined persistent barriers.

IMPLICATIONS FOR PRACTICE

Skin-to-skin care, holds, and APT practices are feasible and safe for term and preterm infants receiving highly instrumented and complex cardiac and surgical care.

IMPLICATIONS FOR RESEARCH

Future research regarding the intervention's impact on neurodevelopmental outcomes of infants and on parent resilience in the surgical and cardiac neonatal intensive care unit is warranted.

Physiology of Stress and Use of Skin-to-Skin Care as a Stress-Reducing Intervention in the NICU

Advances in neonatal care have allowed for the increasing survival of critically ill infants. These infants experience significant stress related to painful procedures and physical separation from their parents. The purpose of this article is to describe the physiologic stress mechanisms that contribute to mortality and morbidity in infants in the NICU and the physiologic mechanisms by which skin-to-skin care (SSC) acts on the stress response system. Findings from current literature supporting the use of SSC and barriers and facilitators to implementation are reviewed. SSC is a safe and effective intervention to reduce stress for infants and their parents. Nurses play a key role in facilitating SSC to optimize outcomes of care in the NICU.

Developing a reporting guideline to improve meta-ethnography in health research: the eMERGe mixed-methods study

Background

Meta-ethnography is a commonly used methodology for qualitative evidence synthesis. Research has identified that the quality of reporting of published meta-ethnographies is often poor and this has limited the utility of meta-ethnography findings to influence policy and practice.

Objective

To develop guidance to improve the completeness and clarity of meta-ethnography reporting.

Methods/design

The meta-ethnography reporting guidance (eMERGe) study followed the recommended approach for developing health research reporting guidelines and used a systematic mixed-methods approach. It comprised (1) a methodological systematic review of guidance in the conduct and reporting of meta-ethnography; (2) a review and audit of published meta-ethnographies, along with interviews with meta-ethnography end-users, to identify good practice principles; (3) a consensus workshop and two eDelphi (Version 1, Duncan E, Swinger K, University of Stirling, Stirling, UK) studies to agree guidance content; and (4) the development of the guidance table and explanatory notes.

Results

Results from the methodological systematic review and the audit of published meta-ethnographies revealed that more guidance was required around the reporting of all phases of meta-ethnography conduct and, in particular, the synthesis phases 4–6 (relating studies, translating studies into one another and synthesising translations). Following the guidance development process, the eMERGe reporting guidance was produced, comprising 19 items grouped into the seven phases of meta-ethnography.

Limitations

The finalised guidance has not yet been evaluated in practice; therefore, it is not possible at this stage to comment on its utility. However, we look forward to evaluating its uptake and usability in the future.

Conclusions

The eMERGe reporting guidance has been developed following a rigorous process in line with guideline development recommendations. The guidance is intended to improve the clarity and completeness of reporting of meta-ethnographies, and to facilitate use of the findings within the guidance to inform the design and delivery of services and interventions in health, social care and other fields. The eMERGe project developed a range of training materials to support use of the guidance, which is freely available atwww.emergeproject.org(accessed 26 March 2018). Meta-ethnography is an evolving qualitative evidence synthesis methodology and future research should refine the guidance to accommodate future methodological developments. We will also investigate the impact of the eMERGe reporting guidance with a view to updating the guidance.

Study registration

This study is registered as PROSPERO CRD42015024709 for the stage 1 systematic review.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Human papillomavirus vaccine acceptability and decision-making among adolescent boys and parents: A meta-ethnography of qualitative studies

OBJECTIVE

Genital warts and human papillomavirus (HPV)-associated cancers in men can be substantially reduced through HPV vaccination; yet, globally, HPV vaccine uptake among boys remains low. This meta-ethnography synthesizes qualitative studies to understand, in-depth, HPV vaccine acceptability and decision-making among adolescent boys and/or their parents.

METHODS

A systematic search identified qualitative studies examining HPV vaccines from the perspectives of boys and/or boys' parents. The Consolidated Criteria for Reporting Qualitative Research (COREQ) 32-item checklist was used to assess quality of reporting. Using meta-ethnographic techniques, we conducted a structured and iterative process of data analysis, coded original studies, and then developed descriptive and analytic themes to synthesize the findings.

RESULTS

Review of 15 eligible studies (n = 3362 parents, n = 39 boys) revealed multilevel factors that influence HPV vaccine acceptability and decision-making among adolescent boys and their parents: (1) individual, e.g., low HPV vaccine knowledge/awareness, (2) interpersonal, e.g., key relationships between parents, sons, and healthcare providers (HCP), (3) community/societal, e.g., parental duty to protect, and (4) systemic, e.g., HPV vaccine messaging. Parents generally accepted adolescent boys' sexuality and the need for vaccination, motivated by wanting to protect their sons from HPV and HPV-associated cancers, and valued HCP-initiated discussion and recommendation. Acceptability was mitigated by low awareness/knowledge of HPV vaccines and low perceived benefits for boys, lack of HCP-initiated discussion, out-of-pocket costs, multiple doses, stigma, and mixed messages about HPV.

CONCLUSIONS

Multilevel factors influence HPV vaccine acceptability and decision-making among parents and their adolescent sons. Providing clear and unambiguous messages about HPV vaccines-for whom (boys and girls), for what (genital warts and cancers in men), and when (before sexual debut)-through increased HCP-initiated discussion and targeted public health campaigns may support HPV vaccine uptake among boys. Future research should consistently disaggregate findings by sex of child and parent, and explore effective messaging tailored for boys and parents.

Noninvasive Ventilation in Premature Neonates

BACKGROUND

The use of noninvasive ventilation is a constantly evolving treatment option for respiratory disease in the premature infant. The goals of these noninvasive ventilation techniques are to improve gas exchange in the premature infant's lungs and to minimize the need for intubation and invasive mechanical ventilation.

PURPOSE

The goals of this article are to consider various uses of nasal interfaces, discuss skin care and developmental positioning concerns faced by the bedside nurse, and discuss the medical management aimed to reduce morbidity and mortality. This article explores the nursing role, the advances in medical strategies for noninvasive ventilation, and the team approach to noninvasive ventilation use in this population.

SEARCH STRATEGY

Search strategy included a literature review on medical databases, such as EBSCOhost, CINAHL, PubMed, and NeoReviews.

FINDINGS

Innovative products, nursing research on developmental positioning and skin care, and advanced medical management have led to better and safer outcomes for premature infants requiring noninvasive ventilation.

IMPLICATIONS FOR PRACTICE

The medical focus of avoiding long-term mechanical ventilation would not be possible without the technology to provide noninvasive ventilation to these premature infants and the watchful eye of the nurse in terms of careful positioning, preventing skin breakdown and facial scarring, and a proper seal to maximize ventilation accuracy.

IMPLICATIONS FOR RESEARCH

This article encourages nursing-based research to quantify some of the knowledge about skin care and positioning as well as research into most appropriate uses for noninvasive ventilation devices.