South University NICU Culture of Care for Infants Qualitative Critique

South University NICU Culture of Care for Infants Qualitative Critique South University NICU Culture of Care for Infants Qualitative Critique Assignment details attached below. – Must be APA format – Only use reference given below. – Please follow instructions and answer all questions on assignment document! – I also included a Qualitative Critique Guidelines below. ethno_nicu_nas.pdf qualitative_research_critique_guidelines.pdf nsg_3036_qualitative_critique.docx ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS NICU Culture of Care for Infants with Neonatal Abstinence Syndrome: A Focused Ethnography Monica Marie Nelson, PhD, MEd, RN Disclosure The author has no relevant financial interest or affiliations with any ­commercial interests related to the subjects discussed within this article. No commercial support or ­sponsorship was provided for this educational activity. Abstract Purpose: The purpose of this focused ethnography was to describe the culture of care and nonpharmacologic nursing interventions performed by NICU nurses for infants with neonatal abstinence syndrome (NAS). Method: Roper and Shapira’s1 framework for the analysis included participant observation, individual interviews, and examination of existing documents. Sample: Twelve full-time nurses were observed and interviewed. Results: Results described the culture of care provided to infants with NAS by NICU nurses as evidenced by six themes: learn the baby (routine care, comfort care, environment, adequate rest and sleep, feeding), core team relationships (support, interpersonal relationships), role satisfaction (nurturer/ comforter, becoming an expert), grief, making a difference (wonderful insanity, critical to them), and education and care of the mother. Keywords: neonatal abstinence syndrome; nurse; culture; caring; focused ethnography A Accepted for publication January 2016. lthough the nursing liter atur e addresses the quantitative measurement of pharmacotherapy and withdrawal from maternal substances for infants with neonatal abstinence syndrome (NAS), little research has been conducted on the nonpharmacologic nursing interventions used to care for these infants. Besides the MurphyOikonen and colleagues 2 study, there is scarce literature regarding the experiences of nurses and the culture of care that is provided for these infants in the inpatient hospital setting. Intrauterine opioid exposure can result in NAS, causing preterm and term infants to withdraw from the drugs taken by their mothers. Current national findings indicate that illicit drug use is 18.3 percent among pregnant teenagers, 9.0 percent among pregnant women aged 18–25 years, and 3.4 percent among pregnant women aged 26–44 years. 3 As the percentage of pregnant mothers who use and abuse addictive substances increases, so will the incidence of NAS. Infants with NAS are increasingly being cared for in the inpatient hospital setting by NICU nurses. Interventions used for the care of preterm and sick infants in the NICU may or may not be the exact interventions that should be used for the care of the fragile infant with NAS. Research studies on the nonpharmacologic nursing care of infants with NAS encompass five main areas of practice: environment, adequate rest and sleep, feeding, assessment and evaluation using Finnegan scoring by nurses, and nurses as caregivers.4,5 Most agree that infant comfort measures, including a quiet environment, swaddling of the infant in a blanket, low light levels, minimal handling while sleeping, rocking, use of a swing, and generous use of a pacifier all contribute to the decreased stimulation required by infants with NAS.5–9 However, N E O N ATA L N E T W O R K VOL. 35, NO. 5, SEPTEMBER/OCTOBER 2016 © 2016 Springer Publishing Company287 http://dx.doi.org/10.1891/0730-0832.35.5.287 most nonpharmacologic nursing interventions have not been empirically tested.6,10. South University NICU Culture of Care for Infants Qualitative Critique Most of the research involving infants with NAS is not recent except the literature on breastfeeding,11–14 assessment using the Finnegan scoring by nurses,15 and nurses as caregivers.2,16 Because of the increased numbers of infants with NAS being cared for in the hospital setting, NICU nurses are caring for infants with NAS along with the preterm infant. Nursing interventions used for both preterm and sick infants and infants with NAS include the assessment of the infant, vital signs, feedings, rocking, diaper changing, swaddling, placing in a swing, medication administration, use of pulse oximetry, and cardiac monitoring. Along with nursing interventions, nurses provide a culture of care to infants. Culture, defined in the discipline of anthropology, represents two main conceptualizations: behavioral and cognitive. Behaviorally, Harris17 defines culture as the behaviors, customs, and way of life observed by a group. Nurses in a group caring for patients have specific behaviors in the group. Observations and descriptions of behaviors explain how and why they do what they do. The concept of caring is considered central to nursing.18(pp8–9) Responding to each person as a unique individual, the caring nurse perceives and responds to the specific needs of patients.19 Therefore, Watson’s definition of caring depicts the nurse providing individualized care to patients. For the purpose of this article, care/caring will be defined as intentional and holistic care to infants. The purpose of this focused ethnographic study was to explore and describe the culture of care (the how and why) and the role of nonpharmacologic nursing interventions used by NICU nurses who provide care to infants with NAS. METHOD Research Design Roper and Shapira’s1 framework for the analysis of focused ethnographic data was used to describe the culture of care provided by NICU nurses for infants with NAS at a children’s hospital in the southeastern United States. The NICU is a 44-bed unit, which is used for the care of preterm and sick infants. A few years ago, a 16-bed NAS unit (NICU 3) was initiated on another floor of the hospital to care exclusively for infants with NAS. Nurses from the NICU work in both the NICU and the NAS unit (NICU 3). Nurses who predominantly (scheduled to work in NICU 3 instead of NICU 1 and NICU 2) work in NICU 3 are called the “core team.” At the time of this research, there was a combination of 16 fulltime and 10 part-time nurses who worked in NICU 3. This focused ethnography included participant observation, individual interviews, and the examination of existing documents. One of the research goals was to identify the meaning of the nurses’ actions and beliefs by observation and individual interviews. Another goal was to bring the insider/outsider view to this ethnographic report and provide deeper insights than the nurses or researcher alone could bring.1 Participants Prior to the initiation of data collection, approval was obtained from the health care setting’s institutional review board (IRB). South University NICU Culture of Care for Infants Qualitative Critique A purposive sample of NICU 3 registered nurses who were employed by the hospital was observed and interviewed. Initially, 16 registered nurses from the core team in the NAS unit provided consent for participation in the study. Twelve nurses (75 percent) consented to interviews after all 16 full-time nurses were invited. Four of the nurses declined because of vacations and extended travel time to the hospital. Each nurse was actively involved in the care of infants with NAS on the 16-bed NAS unit. Participants’ firsthand experiences within the culture being studied provide the data to be described for meaning. The participants have specific knowledge of the culture and are chosen for the purpose of sharing that knowledge with the researcher.1,20 Inclusion criteria require that each nurse be a NICU staff nurse, provide direct patient care, and predominantly work in NICU 3. Of the 12 nurses who participated in interviews, 11 were registered nurses and 1 was a licensed practical nurse. Nurses ranged in age from 27 to 63 years with a mean of 46.1 years, and all of the nurses were Caucasian women. The nurse’s years of experience in the NICU were from 3 to 38 years, with a mean of 15.5 years. All of the interviewed nurses had worked on the 16-bed NAS unit for three years. Written informed consent was obtained from all participants for observations and interviews. Participant observation is the part of ethnographic fieldwork where the researcher is “learning from people.”21 This gathering of data by participating in the daily lives of the members of a group allows a sense of discovery that cannot be obtained by interviews alone. Active involvement in the natural setting allows an outsider to become an insider to experience a culture.1,21,22 Participant observation occurred over six weeks, with more than 80 hours observing and interacting with the nursing staff. These observations helped the primary researcher to formulate questions for the ethnographic interview. Participants were invited to participate in a one-hour interview to be conducted in a private and quiet setting. Semistructured interviews were conducted, and each interview was audio recorded. Transcribed recorded interviews were stored on a password-protected computer. Interviews lasted until saturation was reached. Creswell 23(p240) defines saturation as a point when no new information can be added to the data to bring more understanding. The repetitive nature of findings reveals to the researcher that saturation has been achieved.20 Existing documents may take the form of historical records, maps, policies, procedures, biographical data, charts, graphs, and census figures and may provide data that are useful to the research question.1 During individual interviews, participants were asked open-ended questions regarding the culture of care they provide to infants with NAS. Each nurse was interviewed one time by the primary researcher, with the interviews lasting N E O N ATA L N E T W O R K 288 SEPTEMBER/OCTOBER 2016, VOL. 35, NO. 5 from one to one-and-a-half hours. South University NICU Culture of Care for Infants Qualitative Critique Each nurse was also asked about each of the nonpharmacologic nursing interventions (environment, adequate sleep and rest, feeding, assessment and evaluation using Finnegan scoring, and the role of the nurse) regarding how and why they performed these interventions. Questions Used in the Study The researcher was assisted by a second researcher in developing the interview questions. The questions were openended, and each participant was encouraged to speak freely about his or her experiences in providing a culture of care for infants with NAS. The following questions were asked: 1. What is it like caring for infants with NAS? 2. What is the type of care that you provide for these infants? 3. When you think about caring for these infants, what would you consider as a support in providing the care for these infants? 4. Are there any barriers to providing care? 5. What are the successes you experience in working with these infants? 6. What are the challenges/hardships in working with these infants? 7. What makes work easier for you? 8. What is it about this unit in particular that makes you want to work here? 9. What is it like working with a specialized team of nurses and other professionals? Specific Nursing Intervention Questions: 1. What effect do light, noise, and touch have on NAS infants? What do you do to control light, noise, and touch? (Environment) 2. Describe how you help an infant with NAS to get adequate sleep and rest? (Adequate rest and sleep) 3. How would you describe feeding an infant with NAS (formula or breast milk)? (Feeding) 4. How would you describe Finnegan scoring? (Assessment and evaluation using Finnegan scoring) 5. What role do you see yourself in with these infants? (Role of the nurse) Each nurse was also asked about what led him or her down a path in the NICU, years of working in the NICU, demographic data, and how he or she came to be a part of the core team of nurses who work in NICU 3? DATA ANALYSIS Findings from participant observations recorded as field notes and transcribed interviews were coded. The researcher observed the core team nurses for six weeks (day and night shifts) as they cared for infants with NAS. Field notes were taken each day and recorded within one hour after these detailed observations of nurses. The field notes were descriptive and focused observations of the care the nurses provided to the infants. These observational codes were clustered into categorizes which revealed six themes that helped the researcher to understand the beliefs and feelings of nurses as they provide a culture of care for infants with NAS. All analyses of codes, categories, and themes were reviewed and confirmed by two other researchers. Multiple reviews were conducted to corroborate the patterns of nurses’ statements into themes. RESULTS Six themes emerged that helped the researcher to understand the beliefs and feelings of nurses as they provide a culture of care for infants with NAS. These six themes are (1) learn the baby (routine care, comfort care, environment, adequate rest and sleep, feeding), (2) core team relationships (support, interpersonal relationships), (3) role satisfaction (nurturer/comforter, becoming an expert), (4) grief, (5) making a difference (wonderful insanity, critical to them), and (6) education and care of the mother. Four of the five nonpharmacologic nursing interventions are subthemes and are part of the how the nurse cared for an infant with NAS (Figure 1). South University NICU Culture of Care for Infants Qualitative Critique Theme 1: Learn the Baby Nurses repeated the phrase “learn the baby” during participant observation and interviews. This phrase is defined as the process of learning the individual comfort measures needed to provide care and comfort for the infant. Another way that “learn the baby” was explained was the intentional learning of the baby’s personality. The process of learning the baby occurs through routine care, comfort care, and the nonpharmacologic nursing interventions of environment, adequate rest and sleep, and feeding. Participant 7 described the process of learning the baby as the nurse’s intentional understanding of individual infants: You know of course we do our assessments and do all those things we’re supposed to do, but I guess we look at it more as a whole, meeting their needs and that’s different with every baby. Like you can have 10 lined up and they’re all gonna have different things that make them feel better or maybe better, positions you feed them or it’s learning their habits and I think that’s a big plus with core team is you get to know their little quirks. This trial-and-error approach to the nurse’s use of nursing interventions for infants with NAS appeared throughout the participant observation period and was stated in the individual interviews. All of the interviews were with core team nurses, and every nurse referred to the fact that core team nurses knew the comfort measures that were needed to care for the infants for whom they were responsible. Over time, day after day, the core team nurse learns the baby’s comfort needs. N E O N ATA L N E T W O R K VOL. 35, NO. 5, SEPTEMBER/OCTOBER 2016 289 Routine Care. Through observations of nurses in the NAS unit and by individual interviews, routine care can be described as a set of nursing interventions performed every three hours with infants. These nursing interventions include a physical assessment, Finnegan scoring one hour after feedings, vital signs, blood pressure if an infant is receiving the medication clonidine, diaper changing, changing of clothes if soiled, the administration of medications, and feeding. The next routine care, three hours later, will include all of the previously mentioned nursing interventions but will not include a full physical assessment. Nurses will record all of the routine care nursing interventions every three hours. At the end of the feeding, the nurse may need to hold the infant, reswaddle the infant, provide a pacifier, turn on soft music, or turn down the lights to create an atmosphere of rest and sleep for the infant. If the nurse needs to perform routine care on another infant, a fussy infant may be handed to a patient care assistant (PCA) or to a volunteer cuddler. If a PCA or a cuddler is not available, the infant may need to be placed in the swing to provide a rocking motion to help the infant to sleep. Comfort Care. Between the routine care provided every three hours for infants, many infants become fussy, irritable, have stomachaches, need a diaper change, need to suck on a pacifier, become unswaddled and need to be reswaddled, need to be held, need to be talked to, and need to be rocked in a swing or by a nurse. Until an infant with NAS is “captured,” most infants have very fussy periods during the day. An infant is considered captured when the infant is on the highest needed dose of morphine with Finnegan scores 8 and lower. Finnegan scores range from 0 to 21, with higher scores .8 indicating more distress. South University NICU Culture of Care for Infants Qualitative Critique 15 However, many infants may still have fussy periods even after they are captured and have started weaning from their morphine dosages. Comfort care interventions were provided to infants with NAS individually or in combinations to help relieve withdrawal symptoms (see sidebar). These nursing interventions were observed during routine care and in between routine care. Environment. Typically, a NICU nurse understands that the light, noise, and touch in the NICU need to mimic the womb to not overstimulate the preterm or sick infant. The infant with NAS is usually a full-term infant; however, because of the neurologic damage from drugs received in utero, many infants with NAS require decreased light, decreased noise,24,25 and decreased or specific kinds of touching. Of the nurses interviewed and asked the question, “What effect do light, noise, and touch have on infants with NAS?” all of the nurses stated that all of the environmental stimuli needed to be decreased for the infant with NAS, especially before the infant was captured. Most stated that the infants were “hypersensitive” because of the neurologic damage from maternal drugs. Participant 9 responded with Nursing Interventions Observed to Comfort Infants During Routine Care and In-between Care Swaddling (tight swaddle, hands covered swaddle, Halo swaddle) Holding and rocking Talking/singing to the infant Rhythmically patting the infant’s bottom Lights off—dark room Quiet room Soft music, sound machine, TV off, white noise from sound machine or TV Looking at the infant Pacifier Infant riding in a stroller Infant strapped to a nurse with a front backpack or Moby wrap Swing Infant’s abdomen on nurse’s legs to help with abdominal discomfort Heel warmer to infant’s abdomen over a thin layer of clothing Infant’s hands covered with mittens to protect the skin this comment about the effect of light, noise, and touch on infants with NAS: If they’re uncaptured and they’ve just come in, then we keep the shades drawn, we keep the lights out, the noise down because they’re very sensitive to all those things and it can start some screaming in such a way that it’s hard to get them calmed back down. Now as they age, we try actually to expose them to those things because it would not be beneficial to a baby to be in a controlled environment with the shades drawn then [whispering] “everyone talks really low,” and then suddenly you send ’em home with a parent who has three other kids and it’s chaotic, that would just flip them, for they wouldn’t be able to organize themselves to do the things that we want them to do, so we start talking to ’em, we turn on the lights, we try to get ’em into a rhythm, you sleep then we turn on the lights and talk and we eat and we feed so they have to learn how to socialize, they have to learn how to deal with the stimuli but it stresses ’em them ’til they’re captured. Participant 1 stated, “You need to treat the babies like they have a 300 percent migraine.” This description of the infant with a migraine helps nurses to realize the extreme sensitivity that these infants have to light, noise, and touch. This nurse also stated that the private room for each infant helped with this to provide decreased light, noise, and touch. As with any N E O N ATA L N E T W O R K 290 SEPTEMBER/OCTOBER 2016, VOL. 35, NO. 5 nursing intervention involving … Purchase answer to see full attachment Student has agreed that all tutoring, explanations, and answers provided by the tutor will be used to help in the learning process and in accordance with Studypool’s honor code & terms of service . Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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