الفهرس 
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Abstract
The neonatal intensive care unit environment is a source of continual premature infant dysregulation. Daily stressors as intravenous lines, nurse caregiving, etc. Challenge the behavioral and physiologic capacities of premature infants and impact their long-term developmental outcomes (Héon et al., 2022). This occurs to such an extent that the NICU is often described as a trauma environment and there has been an increasing call for changing NICU practice. Developmental cares are methods that are intended to adjust the NICU environment to diminish the stress, support the behavioral organization, improve physiological stability, keep sleep rhythms, and promote neural growth and maturation of premature infant (Soni et al., 2022).
Aim of the study:
Evaluate the effect of creating healing environment and clustering nursing care on premature infant’s physiological and behavioral outcomes through:
Assessing the physiological and behavioral outcomes of premature infants before creating healing environment and clustering nursing care.
Training nurses about technique of creating healing environment and clustered their care for premature infants.
Evaluating the effect of creating healing environment and clustering nursing care on premature infants’ physiological and behavioral outcomes.
Study design:
An experimental study design.
Study settings:
The study was carried out in the NICUs at Children’s Hospital and Maternity & Gynecological Hospital affiliated to Ain Shams University.
Study subjects:
1-A convenience sample composed of all neonatal nurses (80 nurses) who are working at the previously mentioned settings.
2-A purposive sample composed of premature infants receiving care at the previously mentioned setting. The subjects of premature infants are composed of 53 for control group and 53 for study group.
Inclusion criteria:
Premature infants who having gestational age of 30 - <37 weeks.
Birth weight: 1000–2000 grams.
Exclusion criteria:
Premature infants with major health issues, a congenital anomaly, or hemorrhagic/ischemic brain injury, as well as those who require surgical intervention.
Premature infants on Mechanical Ventilation, phototherapy, and sedative medicines.
Tools of data collection:
Tool I: A Pre-designed Questionnaire Sheet:
It was designed by the researcher after reviewing the related literature and reviewed by supervisors.
Part I: Nurses’ characteristics as age, gender, marital status, residence, qualifications, years of experience, working hours, and attended training courses.
Part II: Neonatal characteristics as gestational age, gender, birth weight, head circumference, medical diagnosis, type of delivery, length of stay at hospital, and APGAR score.
Part III: Neonatal nurses’ knowledge regarding healing environment and clustering nursing care (Pre/Post): It designed by the researcher after reviewing literature reviews as Wang et al., 2020 & Wiley et al., 2020, which included 11 questions at MCQs form and two open end questions.
Tool II. Observation Checklists (Pre/Post): It was adapted from Altimier & Phillips, (2016) and Sathish et al., (2019). It was used to assess nurses’ practices regarding creating healing environment and clustering nursing care, including sound and noise (eight) steps, light, and vision (five) steps, taste and smell (four) steps, touch (five) steps and cluster care (five) steps.
Tool III: Vital Signs Assessment Sheet (Pre/Post for Study and Control groups): It was used to assess the premature infant’s vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation.
Tool IV. Newborn Behavioral Observation Sheet (Pre / post for Study and Control groups): It was adapted from Nugent et al., (2007). It consists of 17 neurobehavioral observations, which describe the newborn’s capacities and behavioral adaptations from.
Tool V. Premature Infant Pain Profile (PIPP) (Pre / post for Study and Control groups): It was adopted from Stevens et al. (1996). The PIPP is a seven indicators pain measure that includes Gestational age, BS, and heart rate, O2 saturation, Brow bulge, Eye squeeze and Nasolabial furrow “subtotal”.
Tool VI: Neonatal behavioral state: It was adopted from Saliba et al., (2020). It was used to assess behavioral state of premature infants at both groups post feeding by assessing number of minutes at these states Quiet sleep, Active sleep, quite awake, Active alert, Crying.
Validity and Reliability:
The tools of data collection were ascertained by a group of experts in neonatal nursing (three) to assess the adherence of a measure to existing theory and knowledge of the concept being measured (construct) and the extent to which the measurement covers all aspects of the concept being measured (content). Reliability was checking the consistency of results across time, across different observers, and across parts of the test itself, it was measured through coronach alpha test.
Ethical Considerations
The study was approved by the research ethical Committee of Faculty of Nursing, Ain Shams University in November 2020. The researcher was clarified the aim and objectives of the study to nurses and parents of premature infants included in the study before starting. Written approval was obtained from the nurses and parents of premature infants before inclusion in the study. They secure that all the gathered data was confidential and used for research purpose only. The researcher assuring maintaining anonymity and confidentiality of nurses and parents of premature infants’ data include in the study. The researcher assuring no harmful for nurses and premature infants included in the study. The nurses were informed that they allowed for withdrawal from the study at any time.
Fieldwork:
For premature infants at control group;
The actual fieldwork commenced in January 2021 and continued until the end of July 2021, spanning 36 weeks. For premature infants in the control group, nurses administered routine care. The researcher then assessed sleep behaviors using the Neonatal Behavioral State ”Tool VI,” which covers a range from quiet sleep to full cry. Vital signs, including respiration, heart rate, temperature, systolic/diastolic blood pressure, and oxygen saturation, were recorded using the Vital Signs Assessment Sheet ”Tool III” for premature infants, within 45 minutes after feeding. Throughout the entire observation period, no interventions were performed on the premature infants. The Premature Infant Pain Profile ”Tool V” was employed to record changes in heart rate, decreased oxygen saturation, brow bulge (seconds), eye squeeze (seconds), and nasolabial furrow (seconds) half an hour after routine daily care activities such as changing diapers, eye care, cord care, and feeding at 10:00 a.m. and 1:00 p.m. Finally, the researcher used the Neonatal Behavioral Observation ”Tool IV” to assess premature infants’ behavior. This was the concluding tool used in the study, and the ages of the premature infants ranged from 10 to 16 days.
For nurses
The researcher trained nurses who provide care for the premature infants at study group about technique of clustering nursing care and creating healing environment through education program through three phases ”assessment, intervention and evaluation”.
Assessment of nurses (Pre):
The researcher distributed a questionnaire to the studied nurses for assessing their knowledge and observed their practices dependent on previous designed observational checklists regarding creating a healing environment and applying clustered nursing care for premature infants. The educational program was prepared and designed according to the nurse’s needs according to pretest.
Intervention phase:
The researcher organized the participating nurses into five groups, with each group receiving training through a combination of three one-hour sessions consisting of lectures and seminars, as well as three practical sessions involving on-the-job training, each lasting for 30 minutes. Nurses were informed about their designated groups through invitation letters, specifying the time and location of the training. The theoretical sessions, conducted by the researcher, took place in the NICU’s conference hall, while the two practical on-the-job training sessions were implemented in the NICUs over ten consecutive weeks on Saturdays, Wednesdays, and Thursdays. These one-hour sessions occurred every week from 10 a.m. to 11 a.m.
Evaluation phase for nurses (Post):
The researcher concluded the training program by summarizing its content and inviting nurses to share any questions or feedback in an open discussion forum. Following this, the nurses were asked to complete a posttest questionnaire, and their practices were assessed using the same study tools employed before the intervention.
For premature infants at study group:
After creating the healing environment and clustering nursing care for one week, the researcher examined the sleep behaviors by using neonatal behavioral state ”tool VI” which range from quiet sleep to full cry and vital signs (Respiration, heart rate, temperature, systolic/diastolic blood pressure, and O2 saturation) by vital signs assessment sheet ”tool III” for premature infants for 45 minutes after the premature infant was fed. During the whole period of observation of the sleep behaviors in the premature infant within 45 minutes, no intervention was performed on the premature infants.
Premature infant pain profile ”tool V” (change in heart rate, decrease O2 saturation, Brow bulge (sec), Eye squeeze (sec) and Nasolabial furrow (sec) were recorded half an hour after the routine daily care as “change diaper, eye care, cord care, feeding” at 10.00 a.m. and 1 p.m. Finally, researcher used NBO ”tool VI” to assess premature infants’ behavior. That was the last tool used in the study, and the premature infants’ ages ranged from 10 to 16 days.
The NBO can be used to track the process of self-regulation as the premature infant attempts to stabilize his autonomic, motor, and state behavior, and prolong his periods of alertness and social availability over the first weeks and months of life. Observation is made with the use of a rattle, a red ball, and a flashlight; the procedure takes approximately 10 minutes. The NBO was performed with one dyad at a time, in the room where they were admitted, between feedings. The sleep and wakefulness states were evaluated at the beginning of the observation. Procedures for habituation to light and sounds were performed only when the child was in a light or deep sleep. The examiner briefly shines a light into a sleeping baby’s eyes. Generally, the child blinks and squirms in irritation. When we repeat the process several times, the infant usually tunes out the stimulation and remains asleep. The baby’s ability to ignore the stimulation allows her to conserve energy and develop.
Results:
-Mean age of nurses was 28.99±7.43 years, and less than three quarters (73.7%) of them were females, nearly two thirds (66.2%) of them married. Mean of years of experience was 9.45±3.87 years. More than one quarter (27.5%) of them had attended training courses.
- Mean gestational age of premature infants in study and control group was 32.17±1.20 & 31.99±1.10 weeks, respectively at p value >0.05 and 58.5% & 64.2% of them were female in study and control groups respectively at p value >0.05. Also, mean birth weight of premature infants in study and control groups were 1.340±125.3 & 1.366±170.12 respectively at p value >0.05. Furthermore, the mean Apgar score at 5th minutes were 9.04±0.45 & 9.20±0.64 in study and control groups respectively, at p value >0.05.
-Less than two thirds (62.4%) of the studied nurses had poor knowledge about developmental care pre intervention, on other hand, less than two thirds (60.0%) of them had good knowledge post intervention, with high statistically significant difference at p value <0.01**.
-The majority (83.8%) of studied nurses had incompetent practice about developmental care pre intervention, on other hand, majority (81.3%) of them had competent practice post intervention, with highly statistically significant difference at p value <0.01**.
-Mean score level for length of stay at hospital among studied premature infants, it was 20.5±2.10 days in study group, and 26.21±4.07 in control group, with highly statistically significant difference at p value <0.01**.
-Mean of respiratory rate at study group was 41.13±4.70 c/m, while at control group was 47.60±5.78 c/m at p value <0.01**. Also, mean of O2 saturation at study group was 96.44±2.70, while at control group was 94.29±3.29 at p value <0.05*.
-81.2% and 11.3% of study group had moderate and better total newborn behavioral observation, while 66% and 28.3% of control group had moderate and low total newborn behavioral observation, respectively. Additionally, there was highly significant difference between study and control groups at p value <0.01**.
-Mean of quite sleep at study group was 19.33±4.78, while at control group was 6.42±2.87, at p value <0.01**. Also, mean of active sleep at study group was 24.66±4.71, while at control group was 21.9±3.99, at p value <0.01**.
-The majority of studied premature infants (90.6%) in study group had mild total premature infant pain profile, while more than one third (37.7%) of them in control had moderate pain score.
Conclusion:
In conclusion, the implementation of healing environments and clustering nursing care had a positive impact on the organizational state, sleep patterns, and responsiveness/interaction of premature infants. However, no discernible effects were observed in the motor and autonomic domains. Notably, the application of healing environments and clustered nursing care was associated with a reduction in the length of premature infants’ hospital stays and an increase in their body weight. Furthermore, the adoption of a healing environment and clustered nursing care significantly improved vital signs such as respiration, heart rate, oxygen saturation, and systolic blood pressure among premature infants. Furthermore, the educational program and on-the-job training exhibited a substantial enhancement in nurses’ knowledge and practices related to the application of healing environments and clustering nursing care.
Recommendations:
Continuous training programs should be applied for nurses in the NICUs to improve their knowledge and practices regarding developmental supportive care, healing environment and clustering nursing care.
Continued implementation and refinement of healing environments and clustered nursing care in neonatal units.
On job training for neonatal nurses about applying healing environment and clustering nursing care.
Design a procedure manual about the healing environment and clustering care for preterm and low birth weight infants in NICUs based on evidence-based practice guidelines.
Training program for mothers of premature infants about the neurodevelopmental of premature infants and methods of assessing that.
Conduct further research to investigate the long-term effects of healing environments and clustered nursing care on premature infants.
Pre discharge plan for families about healing environment to appropriately stimulate and improve premature infants’ neuro-behavioral development and to establish a healthy bonding.
Further study to assess factors affecting neurodevelopmental and physiological outcomes of premature infants.
Establish systems for continuous monitoring of outcomes related to healing environments and clustered nursing care.