Exploring the Relationship Between Mother and Baby Essay

Exploring the relationship between mother and baby in the NICU in relation to nursing support. Abstract Aim -To explore the effect of interaction related to care-giving and information exchange between nurses and mothers in relation to maternal stress and maternal-infant relationship in the newborn intensive care unit (NICU) throughout the hospital stay. Background – Mothers in the NICU experience depression, anxiety, stress, and loss of control, and they fluctuate between feelings of inclusion and exclusion related to the provision of health care to their neonate. This literature review helps to identify nursing interventions that promote positive outcomes between mother and baby by reducing maternal feelings of stress and anxiety. Search Method – A literature search covering the period 2008-2012 was conducted. Five articles reporting both quantitative and qualitative studies relative to the subject were retrieved. Findings – Findings reveal that positive and trustful relationships between nurses and mothers develop when nurses communicate and interact with mothers. This alleviated mother’s anxiety and enhanced their confidence when interacting with their baby. Discussion – Critical analysis as well as strengths and weaknesses of the relative journals reviewed is given together with useful recommendations that emerge from the evidence. Conclusion – The literature reviewed shows that nurse-mother interaction improves mother-infant relationship. In turn, this will eventually assist in decreasing maternal stress and improve the maternal well-being. INTRODUCTION Mothers develop attachment to their baby during pregnancy, which continues and develops more fully after the child is born (Cleveland 2009). However, the pathway to becoming a mother is threatened with the admission of the baby to the NICU. This occurs due to the unfamiliar and intimidating environment of the NICU (Obeidat et al 2009). During the initial admission parents can believe that the healthcare team is more able to care for their baby and this can instill feelings of inadequacy (Cockfort 2011). As a result, maternal attachment may be delayed by the lack of socialisation between mother and baby as most of the care is done by nurses (Cleveland 2009). DeRouck and Leys (2009), found that the parents of an infant admitted to the NICU face challenges including access to information, disclosure about the diagnosis, treatment and prognosis of their newborn, as well as a lack of control over the care of their newborn. Adding to this distress is the uncertainty of survival or the eventual impact of the infant’s condition on later health and well-being. In addition, feeling guilty to mother an unhealthy infant creates fear of social prejudice. Further, the structure of the NICU places significant barriers on mothers’ abilities to enact the parental role since decision-making and the daily care of the infant is taken over by medical and nursing staff restricting interactions with the babies stripping off their maternal authority (Cleveland 2009). In fact, when babies are in the NICU, traditional conceptualizations of the parental role are altered. The situation demands heightened parental participation while simultaneously placing severe restrictions on parental involvement. In response, parents need to negotiate this tension and traditional definitions of the parental role, which must be continually redefined throughout their experience What emerges is that the predominant source of distress is inability of the mother to protect the infant from pain and provide appropriate pain management. (Fenwick et al 2008). A lot of procedures cause pain in the neonate creating concerns for the mother, starting from peripheral cannulas, indwelling catheters and intubation to mention a few. In intubated babies, even though morphine infusions are administered, the baby still shows signs of distress during nursing times. In this case, we administer a small bolus of pain relief prior to nursing so that the baby would be more comfortable. Conversely, Fenwick et al (2008) describes factors that contribute to parents’ satisfaction in the NICU. These include; assurance and psychological support, the provision of consistent information, education, environmental follow-up care, appropriate pain management, and parental participation and proximity, as well as physical and spiritual support. Therefore, it is imperative that nurses should do their best to improve the mothers’ sense of confidence, competence and connection with her infant through guided participation (Domanico et al 2011). Johnson (2008) notes that skin-to-skin holding or kangaroo care promotes maternal-infant feelings of closeness, builds maternal confidence, and may be a stress-reducing experience for both the mother and infant. Hence the importance of providing the opportunity for kangaroo care to occur. Hunt (2008), notes that KMC is also crucial to stabilize parameters, such as cardio-respiratory parameters whilst being beneficial for maintaining body temperature. They add that even the incidence of nosocomial sepsis and the duration of hospital stay decreased with practicing KMC. In addition, Ali et al., (2009), found that Kangaroo mother care also showed positive outcomes towards practicing exclusive breastfeeding. Cockfort (2011) notes that, continuity of care needs to be ensured hence the importance of documentation. Therefore, it is suggested that handover should not be rushed, whilst a more comprehensive handover can ensure the smooth transition of care for staff and the family. When parents ask questions relating to their baby they feel assured in the competency of staff when information has been passed on correctly. When information is not shared effectively parents can lose trust and the partnership breaks down. In Malta, even though handover of 2 consecutive days is given, conflicting advice is still given at times due to the nurses’ different view-points. Consequently, this requires ward meetings in order to clarify important issues so that advice given and practice is consistent. In Malta, about 373 babies are admitted yearly (Grech et al 2012). In view of the benefits discussed, nurses should do their utmost to improve the overall experience of the mothers of such babies. Search Method A review of published research consisted of the following steps; broad reading to determine areas of focus, identification of inclusion and exclusion criteria, literature search (appendix 1) and retrieval, critical appraisal and analysis of the research evidence and synthesis of evidence. Evidence was reviewed with the aims of identifying barriers that affect the motherinfant interaction within the neonatal intensive care unit and how nurses can actively support attachment. Articles were included if the setting was primarily in a neonatal intensive care unit (neonatal unit or neonatal intensive care unit) and the participants were mothers of infants admitted to neonatal intensive care units or nurses working within that setting. In addition, All articles were critically analyzed with two primary questions in mind: (a) What are the needs of parents in the NICU? (b) What nursing behaviors support parents in meeting these needs? Articles were also included if they were primary research studies published between 2008 and 2012 and written in the English language. Primary and secondary literature searches were conducted through the EBSCO, ERIC, Sciencedirect and Medline databases. The primary search terms included â€Å"NICU,† â€Å"Neonatal Intensive Care Unit,† â€Å"family support,† â€Å"communication,† â€Å"nurse† and â€Å"early intervention.† The secondary literature search terms included â€Å"nursing support,† â€Å"efficacy,† â€Å"family,† â€Å"communication,† â€Å"support†, â€Å"neonatal† and â€Å"Kangaroo Mother Care†. These terms were used and utilised in all possible combinations to perform an extensive literature search of the above mentioned electronic databases. Thirdly, a review of references was conducted of the identified articles for any further studies. Eighteen articles were found through the search. Six studies met the inclusion criteria of which, 3 were qualitative and 3 quantitative (appendix 2). The subject was limited to the last 5 years. This time frame helps in the getting the most recent experiences since NICU is a changing environment especially as regards to technology which effects the mothers as well as the nurses. Both quantitative and qualitative studies were found. Both qualitative and quantitative research was conducted to identify what is known about the needs of NICU parents and what behaviours support these parents. Both methods of research were included because of the potential for each to contribute to a more complete understanding of this topic. In selecting a research design, researchers should be guided by one overarching consideration: whether the design does the best possible job of providing trustworthy answers to the research questions. One needs to note that both studies have limitations (Cottrell & McKenzie, 2011). In quantitative research, the researcher’s aim is to determine the relationship between one variable (an independent variable) and another (a dependent or outcome variable) in a population (Morrow 2009). In contrast to quantitative designs, qualitative designs do not result in numerical data for statistical analysis (Schira, 2009). In qualitative methods, researchers are interested in interpreting social phenomena and exploring the meanings that people attach to their experiences (Polit and Beck 2010). Moreover, views, attitudes and behaviours may be explored (Wood & Kerr, 2011), through grounded theory as it develops theories that are â€Å"grounded† in the group’s observable experiences, but researchers add their own insight into why those experiences exist. Findings Table 1 includes information about the 5 studies that met the inclusion criteria . Once an infant is admitted into an NICU, many factors account for parental stress. Admission of the infant to the NICU places mothers in a stressful situation where they must cope with the NICU environment and its associated demands. In the study conducted by Parker (2011), a grounded theory approach was used to understand feeling and stressors of 11 mothers whose new-borns were in the NICU. It was found that the early days shock and numbness accompanied feelings of none or little control over their lives. Moreover, all mothers described feeling unprepared for the premature delivery and the sight of their baby in the NICU. Comparative results were found by Lee et al (2009), with regards to the shock experienced with the initial sight of the baby. Everyday unpredictable changes occur leaving no time for adjustment or preparation. Constant fears about the life and death of the baby do not subside and several mothers spoke about their experience of always anticipating the death of the baby. These findings are also reflected in my clinical setting when mothers would be recounting their experience once the baby’s condition improves. This is in line with the findings of Fenwick et al (2009) and Lee et al (2009). In addition, the findings imply that the positive reassurance of the effects of a positive and caring environment and support network between parents and nurses in the NICU is not always evident among every unit. Nicholas-Sargent (2009) found that assurance is the most important aspect to be fulfilled. Her quantitative study of 46 mothers found that the length of stay in the NICU and mothers’ information needs were found to be significantly inversely correlated. Therefore, this suggests that the longer an infant remains hospitalized in the NICU, the less emphasis the mother places on receiving information about the infant’s condition. This shows that the needs of the mothers in the NICU can change over time. My observations match these findings since mothers familiarise themselves and adapt to the situation. Moreover, they would eventually want to be successful with the care of the baby. This is reflected in the grounded theory analysis conducted by Fenwick et al (2008), using semi-structured interviews. They found that the nurse-mother relationship had the potential to significantly affect how women perceived their connection to the infant and their confidence in caring for their infant which occurred through a three way interaction. Being successful in their desire to care for the baby, engendered feelings associated with being a ‘‘real’’ mother. However, not all women in this study were able to successfully employ these strategies. In the situation where the mother perceived herself as ‘‘quiet and unassertive’’, and in a position without any power, it was very difficult to gain the confidence needed in order to be able to openly question, negotiate and direct the care of her infant. Therefore, it is very important to identify these mothers in order to help them by giving them continuous reassurance. This would particularly be required when the situation changes from support needing to encouragement in participation. Lee et al (2009) found that mothers received support from the healthcare professionals and the social networks that mothers made. These helped to create the connections that developed between the mothers and infants making their journey towards parenthood possible. They discovered that challenges are further compounded in Taiwan, where women are traditionally required to practice the cultural ritual which includes confinement to the house with a special balanced diet for the first month postnatal. Lee et al (2009) used the grounded theory approach with in-depth interviews and constant comparison. All interviews were audio-taped and notes were made during and immediately after the interview concerning actions and body language of the mother during the interview. The finding of this study further indicated that the initial sight of the life-support equipment was shocking. The technological environment created a fearful atmosphere, and the medical equipment attached to their infants caused the mothers further physical separation. The mothers indicated that they were so afraid of the equipment that it took them a long time to be able to participate in their infants’ care. In turn, this hampered them from establishing positive mother–infant interactions. Chiu and Anderson (2008), found that preterm births often negatively influence mother–infant interaction due to lack of physical contact. In addition, they found that skin-to skin contact post-birth has positive effects on infant development. These researchers conducted a randomized controlled trial (RCT) using questionnaires for data collection. In addition, mothers were further video-taped during a feeding session. Ali et al., (2009),highlight the importance of kangaroo care in their RCT where the researchers conducted their study with one hundred and fourteen infants. This study showed that the infants exposed to kangaroo mother care had an increase in rectal temperature compared to conventional care, therefore having a decreased risk of hypothermia. The mean temperature during kangaroo mother care was of 37 degrees Celsius while the mean temperature during conventional care was of 36.7 degrees Celsius. The data collected was through posted questionnaires. Discussion In the 3 qualitative studies found, the data was collected through interviews of which 2 were semi-structured while 1 was unstructured. Parker (2011), Fenwick et al (2008) and Lee et al (2008), used the Grounded theory approach. However, while Parker and Fenwick use semi-structured interviews, Lee uses unstructured interviews. In semi-structured interviews there is a topic guide with list of areas or questions to be covered with each respondent. This technique ensures that researchers will obtain all the information required, and gives respondents the freedom to respond in their own words, provide as much detail as they wish, and offer illustrations and explanations. Lee et al (2009) uses ground theory approach but incorporated with unstructured interviews. Unstructured interviews also known as are flexible but are more time-consuming than semi-structured since the interviewer listens and does not take the lead. The interviewer listens to what the interviewee has to say. The interviewee leads the conversation (Wood & Ross-Kerr, 2011). However, anonymity for confidentiality which is of utmost importance is not possible. When using unstructured interviews, the researchers have to be able to establish rapport with the participant. The reason is that the interviewers have to be trusted if someone is to reveal intimate life information. This may lead to interviewee bias. Also, it is important to realise that unstructured interviewing can produce a great deal of data which can be difficult to analyse. Lee et al (2008) and Fenwick et al (2008) conducted the interviews themselves while Parker (2011) did not, thus reducing the bias. However, interviewer bias occurs even if someone else is conducting the interview. The number of mothers in the study of Lee et al (2008) was adequate since with in-depth interviews 20 participants are enough. However, to account for the small sample, more interviews and observations were done with the same participants in order to reach theoretical saturation. Usually informants are selected for in-depth interviews in a purposive manner questioning the generalizability of the results (Wood & Kerr, 2011). A major controversy among grounded theory researchers relates to whether to follow the original Glaser and Strauss procedures or to use the adapted procedures of Strauss and Corbin (Polit & Beck 2010). Grounded theory method according to Glaser emphasizes induction or emergence, and the individual researcher’s creativity within a clear frame of stages, while Strauss is more interested in validation criteria and a systematic approach. Parker (2011) uses the original Glaser and Strauss (1967) paradigm while Lee et al (2008) and Fenwick et al (2008) use Strauss and Corbin (1998) procedures. One of the fundamental features of the grounded theory approach is that data collection, data analysis, and sampling of study participants occur simultaneously. A procedure referred to as constant comparison is used to develop and refine theoretically relevant categories. Categories elicited from the data are constantly compared with data obtained earlier in the data collection process so that commonalities and variations can be determined. As data collection proceeds, the inquiry becomes increasingly focused on emerging theoretical concerns. All 3 studies use constant comparison. All the above 3 studies use audio-taping for data collection except for Fenwick et al (2008) who used field note documentation as well. Audio-taping enables eye contact to be maintained and to have a complete record for analyses, however, some interviewees may be nervous of tape-recorders. On the contrary, in note taking on the other hand, a lot of eye contact is lost unless a type of short-hand is learnt. However, the interviewer will have plenty of useful quotations for report when transcribing the interview. Randomized controlled trials consist of a complete experimental test of a new intervention, involving the random assignment of a large and varied sample to different groups (Polit & Beck, 2010). The intention of an RCT is to arrive to a judgment as to whether the novelty of an intervention is more effective than the traditional intervention (Polit & Beck, 2010). This intention was well noticed throughout the RCTs chosen by Ali etal., (2009). Wood & Kerr, (2011) sustain that RCTs are the most rigorous method to determine a cause-effect relationship between the treatment and the outcome. Furthermore, RCTs were also described as the gold standard trial for evaluating the effectiveness of a clinical intervention ((Muijs 2010). One of the primary aims of RCTs is to prevent selection bias by distributing the patient, randomly between the two groups, so that the difference in the outcome and results can be justified and attributed only to the intervention under study. Thus, through random selection there is a better balancing of any confounding factors, therefore creating similarity between the groups (Cottrell & McKenzie, 2010). In effect in this literature review, RCTs were found to be useful and beneficial to compare the effect of KMC and conventional care on the physiological aspects of the infant. Ali et al., (2009) chose to add blocking to randomisation so as to ensure a better balance in the number of infants allocated in the groups. These groups were randomized through simple randomization and the disruption of groups was achieved by delivering a concealed envelope technique. Through random sampling, Polit & Beck (2010) explain that each element in the population has an equivalent, autonomous chance of being chosen. However, this design is not used frequently as it is lengthy and may be expensive (Wood & Kerr, 2011). Chiu and Anderson (2008), use mixed methods of data collection by using both questionnaires and video-taped interviews. The use of multiple sources or referents to draw conclusions about what constitutes the truth is called triangulation. This is one approach in establishing credibility as it enables the researcher to counteract the weaknesses in both designs. The use of video-taping provides the most comprehensive recording of an interview since it captures body language, facial expressions and interaction (Gerrish and Lacey 2010). However the interviewee may become uncomfortable and act differently than in normal circumstances questioning the reliability of the data collected. In addition, questionnaires are the main research tools used in quantitative research. They are very advantageous as they can be constructed in such a way as to meet the objectives of almost any research project. In the Family Needs Inventory used by Nicholas-Sargent (2009), the ‘not applicable’ part was removed from the Likert scale in order to report definite opinions. Questionnaires can measure the participants’ factual knowledge about a certain subject or an idea or else they can be used to explore opinions, attitudes or behaviours (McNabb, 2008). Moreover, questionnaires are also less expensive than most other research instruments and are also less time-consuming . Self-administered questionnaires provide the participants with anonymity, and responses are not affected by the interviewer’s mood or presence (Wood & Ross-Kerr, 2011). On the other hand, the main disadvantage of questionnaires is that there is a high possibility of a poor response rate since some questions are ignored, misinterpreted, incorrectly completed or inadequately detailed (Polit and Beck 2010). The RCT of Chiu and Anderson (2009) and Ali etal. (2009),, is one of the most powerful tools of research where people are allocated at random to receive one of several clinical interventions. However RCT’s are vulnerable to multiple types of bias at all stages of their workspan (Geretsegger et al 2012). Hence the need to establish validity and reliability. In the study done by both Ali etal.,(2009) and Chiu and Anderson (2009),the researchers increase the rigor on the study by using a large number of participants. In addition, Chiu and Anderson (2009) use the Nursing Child Assessment Satellite Training Program (NCAST) Feeding and Teaching scales. Nicholas-Sargent (2009), improved the rigour by using the Critical Care Family Needs Inventory (CCFNI), as a framework for the FNI. CCFNI has been thoroughly reported with results indicating internal consistency and construct validity (Gerrish and Lacey 2010). Despite this, Nicholas-Sargent (2009), use a small scale study and therefor e the results cannot be generalized. Limitations In the study done by Lee et al (2008), the data were only collected from one hospital in this present study causing generalisability of the results to be low. Moreover, the sample was restricted to those who did not have additional social, cultural or medical circumstances to consider. Moreover, coding was done by researcher itself and this might have caused some bias. Both Nicholas-Sargent (2009) and Parker (2011) use small scale studies but these were qualitative studies. Therefore, to a certain extent the findings cannot be generalized across the population of families involved with the NICU. In addition, Parker (2011) uses a retrospective study, which might have been subject to bias in recalling information. There was absence of pilot study in both Nicholas-Sargent (2009) and Chiu and Anderson (2009). The use of pilot studies helps to assess the design, methodology and feasibility of the tool and typically includes participants who are similar to those who will be used in the larger research study ( Wood & Kerr 2011). Hence, their importance. Also, the instruments chosen by Chiu and Anderson (2009), being the (NCAST and the feeding and teaching scales) for this study might not be sensitive enough to capture any between-group difference in changes resulting from the intervention. Finally, Ali et al., (2009) fail to mention intention to treat analysis where researchers can introduce reality into research by outlining that not all randomised participants will continue throughout the study. Therefore, this might be a potential weakness in this study. It was also noted the there was no detailed report about the time intervals between the two different groups. Hence, this may also have introduced performance bias. In the grounded theory approach taken by Fenwich et al (2008), limitations lie in the method of data collection itself through semi-structured interviews that were tape-recorded and field note documentation done. The authors did not acknowledge limitations in the study. Recommendations Maternal contact Fenwich et al (2008) suggests prioritising maternal-infant closeness when underpinning policies and protocols and suggests the unrestricted access to their child. Lee et al (2008) found that in Taiwan mothers are allowed to visit for 30 minutes twice a day. In Malta, mothers are allowed to stay with the child 24 hours a day. In addition, skin-to-skin contact is recommended by both Lee et al (2008) and Chiu and Anderson (2009). The latter suggests that all mothers, if they are able and whether or not they ask for it, skin-to-skin contact should be encouraged. My suggestions on interventions for critically ill infants include encouraging the parents’ presence at the bedside, assisting the parents in personalizing the bedside, and teaching the parents to gently touch their infant. Another approach is to hang a simple picture board with the first names of nurses and practitioners near the entrance to the unit. This picture board helps anxious families feel welcomed in this healing environment. In our unit, those babies who have central lines such as umbilical arterial catheters (UAC), the mothers are not allowed to hold the baby for fear of bleeding if the UAC gets dislodged. However, if the mother shows signs of needing contact with the baby, we allow her to hold the baby with constant supervision. In the case of babies that are ventilated mothers are only allowed to hold their baby if the prognosis is very poor. Therefore, this shows that, if the baby is on long term ventilation, skin-to-skin is hindered from being introduced. Fenwich et al (2008), recommend the development of tools that can better evaluate the satisfaction of the mother. Hence, the need for longitudinal qualitative research. In my opinion this would yield good results when past experiences would show which improvements were helpful and which were not. NICE standards (2010), specify the use of surveys. We can incorporate these surveys after consideration with the midwifery officer. Mother-nurse-infant interaction Because of the complexity of illness, parents of critically ill infants are anxious and fear the worst with every visit to the NICU. Strategies need to be adapted to decrease maternal anxiety while supporting the needs of these infants. (Nicholas-Sargent 2009). Nurses play a vital role in helping parents throughout the stressful and challenging experience of the NICU by developing therapeutic relationships and providing emotional support. These approaches enable parents to feel more supported, more involved, confident, and more effective as parents of their vulnerable newborn. The experience of parents in the NICU occurs during an emotionally intense period fraught with anxiety, stress, depression, and feelings of hopelessness. Therefore, Nicholas-Sargent (2009) suggests that, it would be vital to do an NICU orientation for expectant parents with a high risk of giving birth to a premature infant or a compromised newborn. Supporting and facilitating their parenting role will help decrease their stress, strain, anxiety, and depression. Lee et al (2008), nurses need to respect the cultural preferences of mothers as this would promote desired health outcomes. This would aid in meaningful, holistic and individualized care. According to Nicholas-Sargent (2009), personalized one-to-one as opposed as opposed to group support would be helpful. In addition Nicholas-Sargent (2009), suggests that nurse education is needed to improve the awareness of the impact of the counselling service. However, the service needs to be more flexible due to fluctuations in the health condition of the baby. In fact, what we notice is that mothers would require counselling at different stages of the hospitalization. Therefore, if the service was refused once, it may still mean that mothers would need it at some other point in time. Nicholas-Sargent (2009), further suggests that the counselling service would be extended to the whole family from the hospital as well as in the community., Both the DH (2009), and NICE (2010) highlight the importance of Family-Centered Care (FCC) views the family as the ‘child’s primary source of strength and support’ and allows for collaboration, respect, and support with the parents and family during all levels of the service delivery. To foster participation in care for the infant, unrestricted visiting hours should be encouraged for the nuclear family of the neonate. In Malta, visiting hours are restricted to parents only due to increase in cross infection when family members were allowed to visit for 1 hour everyday during the day. However, timing of care may still be arranged to facilitate parents’ participation. In addition, special moments such as baby’s first time off CPAP (continuous positive airway pressure) needs to take place during parents’ presence. Cockfort (2011), highlights that missed opportunities to involve parents in care, heighten anxiety and can create a sense of sadness and loneliness . Information for mothers Mothers vary in the amount of information they can assimilate under stress. Therefore identifying parents’ feelings through active listening and observing will help us to pick up on parents cues and respond appropriately in order to provide parents with accurate and clear information (Fenwick et al 2008). Nicholas-Sargent (2009), adds that, information regarding the health status of the baby needs to be give in a timely provision. Parker (2011), recommends the access to certified interpreters for non-English speaking parents to enable them to ask questions and get the information they need as well as information regarding the counselling services. Likewise, an updated information board at the infant’s bedside helps mothers retain information while feeling welcome at the bedside. In my opinion, these interventions create an environment that facilitates maternal- infant attachment by promoting maternal competence with meaningful positive parenting skills and fostering partnership in care.. Conclusion In summary, the findings showed that parents of infants admitted to the NICU experience stress, depression, anxiety, and feelings of powerlessness, hopelessness, and alienation within the environment of the NICU. These situations are often overwhelming and catastrophic for the mothers keeping in mind that the process of motherhood is a protecting and loving phenomenon. Therefore mothers should participate in the care of their sick, fragile infant in the NICU through mother-infant interaction. Nurses need to be supportive and informative in dealing with parents in the NICU. Therefore, the need for parents to be given the access of interpretation by certified interpreters in order to overcome language barriers has been identified. Further, information and emotional support is required throughout the stay in the NICU, However, it was further found that information in preparation for discharge planning is vital. This enhances parental knowledge and decreases stress, which promotes more effective parenting. Further, as understanding of the parents’ experience of having an infant admitted to the NICU increases, nurses will be better prepared to meet parental needs and alleviate parental suffering. Providing holistic, developmentally supportive care and open communication with parents in this stressful experience is essential. Moreover, the need for family-centered care has been identified. REFERENCE LIST Ali, M.S., Sharma. J., Sharma. R., & Alam. S. (2009). Kangaroo mother care as compare to conventional care for low birth weight babies. Dicle Tip Dergisi. 36(3), 155-160. Chiu S. & Anderson G.C., (2009). Effect of early skin-to-skin contact on mother–preterm infant interaction through 18 months: Randomized controlled trial. International Journal of Nursing Studies, Vol. 46, pp.1168–1180. Cleveland, L.M., 2008. Parenting in the neonatal intensive care unit. Journal of Obstetric, Gynecologic, and Neonatal Nursing, Vol. 37 (6), 666e691. Cockfort S., (2011). How can family centred care be improved to meet the needs of parents with a premature baby in neonatal intensive care? Journal of Neonatal Nursing, Vol.95(5), pp.365-368. Cottrell, R.R. & McKenzie, J. F. (2011). Health Promotion and Education Research Methods using the Five-Chapter Thesis/Dissertation Model (2nd ed.). Sudbury, Canada, United Kingdom: Jones and Bartlett Publishers. DeRouck, S. & Leys, M., (2009). Information needs of parents of children admitted to a neonatal intensive care unit. A review of the literature. Patient Education and Counselling, 76 (2), pp.159-173 DH: Department of Health, 2009. Toolkit for high-quality neonatal services. DH, London. Domanico R., Davis D.K., Coleman F. & Davis B.O. (2010). Documenting the NICU design dilemma: comparative patient progress in open-ward and single family room units. Journal of Perinatology, Vol.31, pp. 281–288 Fenwick J., Barclay L., & Schmied V.,(2008). Craving closeness: A grounded theory analysis of women’s experiences of mothering in the Special Care Nursery. Women and Birth, Vol. 21, pp.71—85. Geretsegger M., Holck U. and Gold C., (2012). Randomised controlled trial of improvisational music therapy’s effectiveness for children with autism spectrum disorders (TIME-A): study protocol. BMC Pediatrics Vol.12(2), pp.1471-2431. Gerrish K. & Lacey A. (2010). The Research Process in Nursing. Blackwell Publishing Ltd. UK. 6th ed. Glaser, B.G., & Strauss, A., 1967. The Discovery of Grounded Theory: Strategies for Qualitative Research. Aldine, NewYork. Gray, D. E. (2009). Doing Research in the Real World (2nd ed.). London, California, New Delhi, Singapore: Sage Publications. Grech V., Cassar M. & Distefano S., (2012). Nurse staffing levels on a regional neonatal paediatric intensive care unit. Journal of Paediatric Intensive Care, Vol. 1(1), pp.25-29. Johnson, A.N., 2008. Promoting maternal confidence in the NICU. Journal of Paediatric Health Care, Vol. 22 (4), 254e257. Lee S., Long A. & Jennifer B. (2009). Taiwanese women’s experiences of becoming a mother to a very-low-birth-weight preterm infant: A grounded theory study. International Journal of Nursing Studies, Vol.46, pp. 326–336 McNabb, D. E. (2008). Research Methods in Public Administration and Non-Profit Management: Quantitative and Qualitative Approaches (2nd ed.). New York: M. E. Sharpe Incorporation. Morrow V., (2009) ‘The Ethics of Social Research with Children and Families in Young Lives: Practical Experiences’. Young Lives. Oxford: Department of International Development. Muijs D., (2010). Doing Quantitative Research in Education with SPSS. London: Sage Publications NICE: National Institute for Health and Clinical Excellence, (2010). Quality Standard for Specialist Neonatal Care http://www.nice.org.uk/media/17A/A8/ Obeidat H.M, Bond E.A. & Callister L.C., (2009). The Parental Experience of Having an Infant in the Newborn Intensive Care Unit. The Journal of Perinatal Education | Summer, Vol. 18(3), pp.23-29. Parker L., (2011). Mothers’ experience of receiving counselling/ psychotherapy on a neonatal intensive care unit (NICU). Journal of Neonatal Nursing, Vol.17, pp.182-189. Polit D.F. & Beck C.T. (2010) Essentials of Nursing Research: Appraising Evidence for Nursing Practice, 7th ed. Wolters Kluwer Health | Lippincott Williams & Wilkins, Philadelphia. Nicholas-Sargent A., (2009). Predictors of needs in mothers with infants in the neonatal intensive care unit. Journal of Reproductive and Infant Psychology, Vol. 27(2), pp.195–205. Schira, M. (2009). Appraising a single Research Article. In Mateo, M. A. & Kirchhoff, K. T. (Eds.), Research for advanced practice nurses: from evidence to practice (pp. 73-85). New York: Springer Publishing Company. Strauss A. & Corbin J.( 1998). Basics of qualitative research. 2nd ed. Newbury Park, CA: Sage Publishers;. Watson, H., Booth, J. & Whyte, R. (2010). Observation. In Gerrish, K. & Lacey, A. (Eds.), The Research Process in Nursing (6th ed.) United Kingdom: Blackwell Publishing Limited. (pp. 382-394). Wood, M. J. & Ross Kerr, J. C. (2011). Basic Steps in Planning Nursing Research: From Question to Proposal (7th ed.). Sudbury, Canada, United Kingdom: Jones and Bartlett Publishers.

Case Analysis- Strategic Marketing Management Study

Analysis- Strategic Marketing Management - Case Study Example Therefore, Nintendo faces the challenge of overemphasizing on innovation per se while ignoring the needs of the mature audience that considers memory and storage capacity as important features of gaming hardware. Furthermore, customer lifestyle and trends are changing with majority of young audience switching to free-to-play versions of games on their smartphones. The report discusses the marketing and competitive environment with respect to Nintendo as well we its segmentation strategy and business strategy in the context or current dynamics. 1. Introduction Nintendo has gained the first-mover advantage in the interactive entertainment sector by providing both gaming devices and associated services since 1983. The Japanese manufacturer has evolved from its cult favorites â€Å"Super Mario† â€Å"Nintendo Game Cube† and â€Å"Nintendo 64† towards its more recent â€Å"Wii† and â€Å"Nintendo DS† (Kim, Lamont, Ogasawara, Park, & Takaoka, 2011). Altho ugh initially aimed at hard-core gamers, the company is aiming towards penetrating the market by appealing to more segments (including women and adults) and appealing to the mass market. It currently faces intense competition from Microsoft’s Xbox and Sony’s Play station. Furthermore, market trends are changing and the dynamics are clearly not the same as they were several years ago. The new generation of young customers is demanding free-to-play mobile games which are a major consideration for Nintendo in the revamping of its strategy. 2. Strategic vision/mission Nintendo’s vision and reflects its commitment to provide the â€Å"highest quality of products and support services† for customers by valuing customer feedback and encouraging teamwork amongst employees (Nintendo Games, 2013). The company’s strategy supports this commitment by providing gaming entertainment that is enjoyed by people of all ages (including women and adults). Keeping custom er feedback in mind and the trend of games of smartphones, the company is currently rethinking its strategy to broaden its target market and include non-gamers compared to hard-core console gamers. Hence, Nintendo is aiming at penetrating the market and rethinking its strategy keeping in view the current market trends of the youth generation moving towards free-to-play games on smartphones (Negishi, 2013). 3. Current marketing strategy Nintendo’s current marketing strategy revolves around its commitment to deliver superior customer service and quality of products. The new console â€Å"Wii† includes a three month warranty along with easy to use interface and free games (Nintendo, 2013). With this, Nintendo has revamped its traditional strategy by positioning the Wii as a universal product suitable for use by all ages and gender groups. The company has capitalized the brand equity associated with the Nintendo brand by retaining the â€Å"console† and innovating b y introducing entirely new product categories through its â€Å"motion sensor† technique (O’Gorman, 2008). 4. Target market and marketing strategy

Ergonomic Problems Essay Example | Topics and Well Written Essays - 750 words

Ergonomic Problems - Essay Example These are all influenced by the psychological/physiological and psychosocial capabilities, limitations, and dimensions of the person; layout, design, position, control, and distance of machine; temperature, lighting, humidity, noise, and vibration of the environment. Explain the role of anthropometrics when solving ergonomic problems Anthropometrics enables the customization of machine controls, position, and design to adapt to the worker’s physical built, equivalent capability, and movements. Explain the role of biomechanics when solving ergonomic problems. Biomechanics help the worker or humans properly adhere to the capabilities of machines through adaptable dynamics modified to the body components. List the categories of workstations Workstation categories vary depending on the industry from engineering, manufacturing, business, robotics, and even homes. There are the computer workstations and music workstations. In the construction industry, these are Architectural Structures, Bricklayer, Building From Blueprints, Carpenter, Cement Mason, Construction Measurement, Drafting (Mechanical), Drywall Installer, Electric Motor Repair, Electrical Wiring / Electrician, Floor Coverings Installer, Glazier / Window Installation & Repair, Hydraulics, Insulation Installer, Landscape Design, Machinist, Painter, Plumber, Pneumatics, Power Mechanics/Small Engine Repair, Residential Plumbing, Residential Wiring, Roofer, Sheet Metal Worker, Telecommunications Technician, Tile Setter, Wall Coverings Installer, Welder, and Woodworker stations.

Geriatric Nursing Care Essay Example | Topics and Well Written Essays - 2500 words

Geriatric Nursing Care - Essay Example Currently he has cellulitis and resultant wounds in the lower portion of both legs is causing severe pain for, which he is being administered Panadol Elixir in six divided doses in a period of 24 hours. Paracetamol is the chosen pharmacological agent for this patient due to his advanced age and likely occurrence of adverse effects if other pain relieving agents such as non steroid anti inflammatory drugs or opiod analgesics were used.The affected leg is kept raised to reduce the discomfort and the wound is dressed daily. The patient is however afebrile, has a blood pressure of 140/95, respiration rate (RR) of 20-37 and a heart rate (HR) of 80 beats per minute at the latest reading. His health parameters have consistently stayed at this level and are normal for a person at this age. However, as the patient has been a regular smoker with established diagnosis of COPD, he needs special care and oxygen therapy as and when required. History of a severe shingles attack shows that the immun ity status is compromised and the patient needs to be kept away from any sources of infection, as his immune system may not be able to cope up with a fresh infection. The patient has already tested positive for methicillin resistant staphylococcus (MRSA) infection and has been treated for the same. Assessment of a patient is the most crucial step which determines the future course of action by a nursing practitioner. Assessment has been defined as the process of collecting, validating and clustering patient data in order to arrive at a broader picture which defines the future course of action (Dillon, 2007). It does not stop at the initial examination of the patient and perusal of... This paper approves that the best method of chronic pain alleviation is however definitely the pharmacologic approach and the choice of the pharmacological agent should be through proper evaluation of the nature of injury, the type of pain and the physical/psychological characteristics of the patient. Drug dosage needs to be closely monitored and modified according to individual requirements with constant monitoring and careful observation. A holistic approach includes usage of non-pharmacological modalities such as physiotherapy and behavioral therapies. This essay makes a conclusion that the actual problems afflicting the client are cellulitis, inability to breathe spontaneously, inability to take food on his own, festering wounds beneath the knees on both legs and general debility associated with old age. The contributing factors include excessive smoking in the past that resulted in COPD, history of testing positive for MRSA infection and hypertension. The prognosis for the patient is grave, as the presented co morbidities are difficult to treat at such an advanced stage of his life. Healing processes are slowed down during old age and the lack of immunity makes such patients susceptible to fresh infections. The initial therapeutic endeavor should be aimed at healing the wounds after which pulmonary rehabilitation can be tried. If the patient is able to overcome these hurdles, the PEG tube can be removed after he gains and strength and acquires the capability to eat normally and carry out his daily activities independently. He nee ds constant nursing care and psychological support until the therapeutic goals are achieved.

Jodi Picoult Research Paper Example | Topics and Well Written Essays - 750 words

Jodi Picoult - Research Paper Example Her first novel titled ‘Songs of the Humpback whale’ was written when she was pregnant with her first child and she found it quite difficult to strike a balance between work and motherhood. It was all these experiences that influenced her second novel titled ‘Harvesting the Heart.’ The basis for this book comprised partly of her balancing act between her career and her life as a mother. As Picoult states - "It took me a while to find the balance," Picoult says, "but I'm a better mother because I have my writing†¦ and I'm a better writer because of the experiences I've had as a parent that continually remind me how far we are willing to go for the people we love the most."  (Jodi Picoult, 2007) ‘Nineteen Minutes’ by Jodi Picoult, is a rather shocking story that is very much relevant in today’s contemporary society. This very interesting story revolves around a young boy named Peter Houghton, who was a victim of bullying right from h is kindergarten up to his High School. The bullying included slamming him into the school lockers, snatching away his lunch and breaking his spectacles to smithereens. (Nann Blaine Hilyard, 2007) Hate builds up over the years and one fine morning in March, Peter goes to school with a gun and shoots down a teacher and nine students within 19 minutes. The author has given a very apt title for this story and with her keen sense of analyzing the current scenario of today’s society, she has the ability to trigger feelings and emotions of people involved in different relationships. Her fictional stories such as ‘Nineteen Minutes’ seems almost lifelike because we see it happening in our lives even today. Her philosophy of life goes beyond sensationalism and creates an awareness not only among parents but also among students, of some of the social issues that face us today. ‘My Sister’s Keeper’ is another enlightening story by Picoult who makes use of multiple narrators to drive home the message of social awareness in contemporary society. The central theme in this story is dependency, that is clearly brought out by 13 year old Anna Fitzgerald who has an older sister Kate. It is rather unfortunate that Kate was afflicted with a rare kind of leukemia and depended on her sister Anna for a variety of blood products. Anna being an allogeneic donor was a fitting sibling match for Kate. (Dignan Jennifer, 2005) Picoult pulls at the heart strings of her audience by making use of different narrators who express their feelings and emotions regarding the happenings in the Fitzgerald household. She involves the readers by shedding light on what life would mean to the donor, the recipient, parents and other children in the family and comes out with the moral, ethical and legal issues that can confront them at every stage of their lives. Though Anna’s parents show a lot of love and concern for her, in the bigger picture Anna understand s that she is there for a purpose and the purpose was to save her sister Kate. (Dignan Jennifer, 2005) Anna feels used and does no quite believe her mother when she says that she and her father love her a lot. This point clearly expresses Anna’s doubt when she states that her mother ‘made sure to say’ that her parents loved her. The bond and respect between both the sisters is very strong even though they quarrel sometimes. Jodi Picoult’s ‘A Change of Heart’ is the gripping tale of a murderer who was on the death row

Is Competition Good Essay Example | Topics and Well Written Essays - 1250 words

Is Competition Good - Essay Example In any case to adequately support competition, authorities must comprehend when competition itself is the issues reason, not its cure. Market competition, while hurting a few members, frequently profits public opinion. Anyhow does competition dependably profit public opinion? (Stucke, 2103) In business, competition prompts innovation. If youre the player in your field, it could be troublesome to progress. And in case youre working in a packed business, you wont succeed by doing what other a person does. Sound competition supports change which will recognize your organization from others through technology, item adjustments or by enhancing the client experience. (Forbes, 2014). Moreover, customer services are enhanced due to competition because as one of a few organizations offering a comparable item, an organization is compelled to vie for clients. Enhancing client administration enhances the chances of customer retention. (Forbes, 2014). Competition also shakes off complacency. In the event that an association is reliably attempting to advance and better itself, their workers will be urged to inspire themselves. (Forbes, 2014). Competition encourages an organization to concentrate on their core customer and target audiences. On the off chance that an organization is f ocusing on a particular geological area or demographic, market challengers sway them to better understand that setting. In doing in this way, they will have the capacity to better accommodate that target demographic/setting. (Forbes, 2014). Seeing what one’s rivals do well can show you things about one’s own business. Their practices may well furnish an organization with profitable knowledge into the state of the business sector, and help demonstrate to them; what works – and what does*3not. (Forbes, 2014) The Late Franklin D. Roosevelt once said: â€Å"Competition has been shown to be useful up to a certain point and no further, but

Discrimination of black people and white people Essay Example for Free

Discrimination of black people and white people Essay This story, Black Boy is a great book that describes how the author, Richard Wright, suffered in the South of the United States during the time when there was still a lot of discrimination throughout the country. Since the author explained many of his horrible experiences in the past, this book cannot be written in a thin book. This thick book is full of his great experiences that wanted to be read by many people in the world in order to let everybody know the disasters of racism. This racism affected Richard Write a lot and he had to adapt to the environment that he was in, although he didn’t know how he should act in front of white people in the beginning of the story. There are not many examples in the beginning of the story since Richard was a little boy, and he still didn’t know about racism. He did know that something was different between black and whites, but he wasn’t able to understand it since he was too young. He even talks to himself in Pg. 49 that â€Å"I had heard that colored people were killed and beaten, but so far it all had seemed remote. There was, of course, a vague uneasiness about it all, but I would be able to handle that when I came to it. It would be simple. If anybody tried to kill me, then I would kill them first. † After this, he realized the harshness of racism around his society when Uncle Hoskins got shot by a white man when he was at the saloon. And the reason is just because a black man was earning a lot of money and the white man became jealous. Also after this scene, there is an another example in Pg. 172 where he met his classmate, Ned Greenley who had lost his brother since the whites shot him for a specific reason. Ned said, â€Å"Th-they said he was fooling with a white prostitute there in the hotel. † Richard was shocked since he could be in those kinds of situations at any time. Richards starts to think of really going to North soon as possible now. In Chapter nine, there is a scene that is really harsh where Richard sees it, but could do nothing. This scene is at the clothing store for black people where Richard worked. The black employees were treated like slaves in the store; the white owners would push, kick, or slap the blacks. Although Richard saw this scene many times, he never got used to it. Another big thing is the time when Richard sees a black woman getting raped by two white men. This is a part from the book that describes how evil this time of period was. On Pg. 179, it says, â€Å"White people passed and looked on without expression. A white policeman watched from the corner, twirling his night stick; but he made no move. I watched out of the corner of my eyes, but I never slackened the strokes of my chamois upon the brass. After a moment or two I heard shrill screams coming from the rear room of the store; later the woman stumbled out, bleeding, crying, holding her stomach, her clothing torn. When she reached the sidewalk, the policeman met her, grabbed her, accused her of being drunk, called a patrol wagon and carted her away. † When I read this scene, it really hurt my heart. I couldn’t believe that the police didn’t do anything at all and although the policeman knew that the black woman was raped, he accused her of being drunken. Richard could have thought of saving the woman, but if he did something to the whites, he could be killed. Therefore, Richard wasn’t able to do anything. All he could do was to feel sorry for the lady. This doesn’t mean that Richard didn’t worry about the woman, it was the way how he had to act in the South. After Richard realizes the social cycle between the whites and the blacks at his work place, he sacrifices his morals to save more money. He begins to bootleg liquor to sell to white prostitutes in the hotel that he worked at. After that, he involves in a ring for scamming tickets. Then, he quickly amasses enough money to move out to the North. Although Richard was working earnest, he quits it because it was very hard to collect money if he had worked earnestly. Since Richard Write had an experience that he does not want to experience anymore, he was able to write this book, which would tell all the readers that discrimination or racism is not a good thing to do. He explained how he had to act as a black man; if he didn’t act like a black man, he might have not gotten the chance of writing this book. Richard Write had explained how blacks should act as a black, and although many horrible things were occurring around him, he wasn’t able to change it since he was just a black man. I feel that Richard really wanted to resist against the white men but if he did, he knew that he was going to be dead. Although in the beginning of the story, he said that, â€Å"If anybody tried to kill me, then I would kill them first†, as a result he wasn’t able to disobey the whites because he was scared of death. Since he was able to adapt to the society that he was in, he was able to earn money and was able to go to the North to have a better life.