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Nurses' perspectives of parental participation in the care of preterm infants in a special care nursery Foster, Norma 1990

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NURSES PERSPECTIVES OF PARENTAL PARTICIPATION IN THE CARE OF PRETERM INFANTS IN A SPECIAL CARE NURSERY B.Sc.N. The U n i v e r s i t y of B r i t i s h Columbia, 1990 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES Department of Mathematics and Science Education We accept t h i s t h e s i s as conforming By NORMA FOSTER to the required standard THE UNIVERSITY OF BRITISH COLUMBIA APRIL 1990 Norma Foster, 1990 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada DE-6 (2/88) A B S T R A C T N u r s e s i n n e o n a t a l s p e c i a l c a r e n u r s e r i e s w i t h a p h i l o s o p h y o f f a m i l y c e n t e r e d c a r e i n v o l v e p a r e n t s i n t h e c a r e o f p r e t e r m i n f a n t s . T h e r e i s l i t t l e r e s e a r c h d e s c r i b i n g n u r s e s ' p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n c a r e . U s i n g i n t e r v i e w d a t a o b t a i n e d f r o m o n e s e c o n d a r y l e v e l n e o n a t a l s p e c i a l c a r e n u r s e r y , t h i s s t u d y a t t e m p t s t o u n d e r s t a n d t h e m e a n i n g p a r e n t a l p a r t i c i p a t i o n i n c a r e h a s f o r n e o n a t a l n u r s e s a n d t h e way t h a t m e a n i n g i s e x p r e s s e d i n v a r i o u s n u r s i n g a c t i v i t i e s . T w e l v e n u r s e s w e r e i n t e r v i e w e d a b o u t t h e i r r e a c t i o n t o p a r e n t a l p a r t i c i p a t i o n i n v a r i o u s a c t i v i t i e s s u c h a s f e e d i n g a n d b a t h i n g t h e i r b a b i e s . T h e s e n u r s e s a r e a l l f u l l t i m e s t a f f members i n t h e n u r s e r y . F i n d i n g s o f t h e r e s e a r c h a r e t h a t t h e r e a r e t w o m a i n n u r s i n g p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n t h e c a r e o f p r e t e r m i n f a n t s i n a s p e c i a l c a r e n u r s e r y . T h e s e t w o p e r s p e c t i v e s a r e l a b e l l e d t h e ' o u r b a b y ' a n d ' t h e i r b a b y ' p e r s p e c t i v e . The ' o u r b a b y ' g r o u p o f s u b j e c t s m a i n t a i n a t r a d i t i o n a l r o l e o f c o n t r o l o f c a r e . The ' t h e i r b a b y ' g r o u p a r e c o m m i t t e d t o t h e p h i l o s o p h y o f f a m i l y c e n t e r e d c a r e w i t h i n c e r t a i n b o u n d a r i e s . A n e x a m p l e o f t h e d i f f e r e n c e . , i n t h e t w o p e r s p e c t i v e s was d i s c o v e r e d i n t h e a r e a o f i n f a n t f e e d i n g . The ' o u r b a b y ' n u r s e s t h o u g h t t h a t p a r e n t s e n g a g e d i n t h i s a c t i v i t y i n c r e a s e d t h e w o r k l o a d w h i l e t h e ' t h e i r b a b y ' n u r s e s t h o u g h t t h a t p a r e n t s d e c r e a s e d w o r k l o a d . The ' o u r b a b y ' n u r s e s t r e a t e d m o s t p a r e n t s i n a s i m i l a r way b u t t h e ' t h e i r b a b y ' n u r s e s i n d i v i d u a l i z e d t h e i r a p p r o a c h t o p a r e n t s . The ' t h e i r b a b y ' n u r s e s ' e n j o y e d s p e n d i n g t i m e w i t h p a r e n t s b u t t h e o t h e r g r o u p s a i d t h a t t h e r e w e r e l e s s p a r e n t s t o d e a l w i t h when t h e y w e r e w o r k i n g a t n i g h t . B o t h g r o u p s w o r k s i d e b y s i d e w i t h l i t t l e c o n f l i c t . I m p l i c a t i o n s f o r t h e s e l e c t i o n a n d t r a i n i n g o f n u r s e s a r e n o t e d a s w e l l a s i m p l i c a t i o n s f o r f u r t h e r r e s e a r c h . i v ACKNOWLEDGEMENT S S p e c i a l thanks are giv e n t o my t h e s i s a d v i s o r , Dr. James G a s k e l l and committee members Dr. P a t r i c i a V e r t i n s k y and Ms. E l a i n e C a r t y . I would a l s o l i k e t o acknowledge the generous c o o p e r a t i o n of the s p e c i a l care nursery i n which t h i s r e s e a r c h was conducted. V TABLE OF CONTENTS A b s t r a c t i i Acknowledgements i v L i s t of Tables v Chapter I PROBLEM AREA 1 Chapter II LITERATURE REVIEW 11 Chapter I I I METHODOLOGY 22 Chapter IV ANALYSIS OF DATA 29 Chapter V DISCUSSION 81 References 92 Appendix I 94 Appendix II 102 1 C H A P T E R I P R O B L E M A R E A 1 . 1 P r o b l e m A r e a F a m i l y c e n t e r e d m a t e r n i t y c a r e i s a common p h i l o s o p y o f h e a l t h c a r e a g e n c i e s i n C a n a d a a s t h e r e i s a g e n e r a l c o n c e n s u s t h a t f a m i l y c e n t e r e d c a r e i n h o s p i t a l s f o s t e r s p o s i t i v e p a r e n t c h i l d r e l a t i o n s h i p s . My c l i n i c a l e x p e r i e n c e i n s p e c i a l c a r e n u r s e r i e s s u g g e s t s t h a t t h i s p h i l o s o p h y i s n o t a l w a y s e m b r a c e d b y a l l o f t h e n u r s i n g s t a f f . The b i r t h o f a p r e t e r m i n f a n t , d e f i n e d a s a b a b y b o r n b e f o r e t h e e n d o f t h e t h i r t y - s e v e n t h week o f g e s t a t i o n ( K o r o n e s , 1 9 8 1 , p . 133) i s o f t e n a c r i s i s f o r b o t h p a r e n t s a n d s t a f f . T h e p a r e n t s c a n n o t l e a r n many p a r e n t i n g s k i l l s w h i l e t h e b a b y i s a t t a c h e d t o l i f e s u p p o r t e q u i p m e n t a n d f r e q u e n t l y many h e a l t h p r o b l e m s o c c u r b e f o r e t h e s e b a b i e s a r e r e a d y t o go h o m e . P r e t e r m b a b i e s r e q u i r e i n t e n s i v e c a r e f o r e x t e n d e d p e r i o d s a n d o f t e n n u r s e s b e c o m e a t t a c h e d t o t h e m a s t h e y p r o v i d e c a r e . Some p a r e n t s h a v e t o c o m p e t e w i t h t h e n u r s e s t o p a r t i c i p a t e i n t h e c a r e o f t h e i r b a b y . A l t h o u g h many n e o n a t a l u n i t s h a v e a d o p t e d a f a m i l y c e n t e r e d p h i l o s o p h y l i t t l e i s k n o w n a b o u t n u r s e s ' i d e a s a n d a c t i o n s w i t h r e s p e c t t o p a r e n t a l p a r t i c i p a t i o n . T h e c o n c e p t 2 of p e r s p e c t i v e as a c o - o r d i n a t e d set of ideas and a c t i o n s a person uses i n d e a l i n g with some p r o b l e m a t i c a l s i t u a t i o n (Becker, Greer, Hughes and Straus, 1961, p.34) i s a u s e f u l way of under s t a n d i n g nurses r e a c t i o n s t o the p o l i c y of p a r e n t a l p a r t i c i p a t i o n . T h i s study w i l l i n v e s t i g a t e nurses' p e r s p e c t i v e s towards i n c r e a s e d p a r e n t a l p a r t i c i p a t i o n i n the care of preterm babies i n a s p e c i a l care or i n t e n s i v e care n u r s e r y . 1.2 Background The b i r t h of a preterm i n f a n t i s a c r i s i s as these babies are not p h y s i o l o g i c a l l y w e l l equipped t o cope with l i f e . T h i s i s evidenced by high e r m o r t a l i t y and m o r b i d i t y r a t e s i n premature b a b i e s . The lungs may not be s u f f i c i e n t l y developed t o al l o w gaseous exchange; t h e r e are d i g e s t i v e problems and some babies cannot t o l e r a t e o r a l f e e d i n g . The immaturity of the immulogical system p l a c e s these babies at g r e a t e r r i s k f o r i n f e c t i o n ; p l u s , they a l s o have d i f f i c u l t y m a i n t a i n i n g normal body temperature. P e r f u s i o n of body t i s s u e s i s marginal due t o l a c k of c a p i l l a r i e s (Korones, 1981, 133) . The maintainance of b a s i c human body f u n c t i o n s of a preterm baby i s a c h a l l e n g e f o r nurses. On t h e i r f i r s t v i s i t t o the s p e c i a l care nursery parents may see t h e i r i n f a n t i n a p l a s t i c box, at t a c h e d t o oxygen equipment with 3 a n i n t r a v e n o u s i n f u s i o n i n e i t h e r t h e h e a d o r t h e u m b i l i c u s . A p r e t e m b a b y i s u s u a l l y s m a l l a n d t h i n w i t h r e d s k i n . The e y e s a r e n o r m a l l y c l o s e d a n d t h e b o d y p o s t u r e f l a c c i d . When a b a b y i s s t r u g g l i n g t o b r e a t h e t h e y h a v e l i t t l e e n e r g y t o i n t e r a c t w i t h t h e p a r e n t s . T h i s s c e n e i s f a r r e m o v e d f r o m t h e p a r e n t a l e x p e c t a t i o n s o f a n a c t i v e , p i n k , f u l l t e r m b a b y . How d o n u r s e s a s s i s t p a r e n t s who a r e o f t e n a f r a i d t o t o u c h t h e i r p r e t e r m b a b y l e t a l o n e t o a c t i v e l y p a r t i c i p a t e i n h i s / h e r c a r e ? S p e c i a l c a r e n u r s e r i e s a r e l i k e t h e i n n e r s a n c t u m o f a c h u r c h t o w h i c h o n l y a p r i v e l e g e d f e w h a v e a c c e s s - p e r s o n s who h a v e s p e c i a l q u a l i f i c a t i o n s a n d d r e s s i n a s p e c i f i c w a y . The l o c a t i o n a n d c o n s t r u c t i o n o f s p e c i a l c a r e n u r s e r i e s d i s c o u r a g e v i s i t o r s a s t h e r e i s o n l y o n e a c c e s s i b l e e n t r a n c e a n d t h e r e i s u s u a l l y s o m e o n e ' g u a r d i n g ' t h e d o o r who w i l l c h a l l e n g e a n y v i s i t o r . O f t e n t h e n u r s e r y i s i n t h e c e n t r a l c o r e o f t h e b u i l d i n g a n d t h e r e a r e n o w i n d o w s . E v e n t h o s e w i t h w i n d o w s o f t e n h a v e c u r t a i n s w h i c h a r e o n l y o p e n e d a t s p e c i f i c t i m e s o f t h e d a y . T h o s e who h a v e v i s i t i n g p r i v e l e g e s a r e c a r e f u l l y m o n i t o r e d a n d g i v e n s p e c i f i c i n s t r u c t i o n s a b o u t how t o gown a n d w a s h h a n d o n e t i m e o n l y s p e c i f i e d h e a l t h c a r e w o r k e r s w e r e a l l o w e d t o e n t e r s p e c i a l c a r e n u r s e r i e s . P a r e n t s w e r e n o t e n c o u r a g e d t o v i s i t . T h e y w e r e c o n s i d e r e d t o b e c a r r i e r s o f i n f e c t i o n , s o 4 i n t e r a c t i o n b e t w e e n p a r e n t s a n d i n f a n t s was l i m i t e d . I n t h e e a r l y s e v e n t i e s K l a u s a n d K e n n e l l , t w o p e d i a t r i c i a n s p r o m o t e d t h e c o n c e p t o f m a t e r n a l i n f a n t b o n d i n g a n d m a t e r n i t y u n i t s b e g a n t o r e v i s e p o l i c i e s a n d p r o c e d u r e s t o i n c o p o r a t e t h i s c o n c e p t . G r a d u a l l y , m o t h e r s w e r e a l l o w e d t o v i s i t a n d t o u c h t h e i r b a b y i n t h e s p e c i a l c a r e n u r s e r y , t h e n f a t h e r s g a i n e d a c c e s s b u t t o u c h i n g was n o t e n c o u r a g e d . T o d a y , n u r s e s i n s p e c i a l c a r e n u r s e r i e s t e a c h b o t h m o t h e r a n d f a t h e r p a r e n t i n g s k i l l s a n d e n c o u r a g e t h e m t o p a r t i c i p a t e i n t h e c a r e o f t h e i r b a b y . F a c t o r s t h a t may a f f e c t t h e s u c c e s s o f o p e r a t i o n a l i z i n g t h e c o n c e p t o f f a m i l y c e n t e r e d c a r e h a v e n o t b e e n i d e n t i f i e d i n n u r s i n g l i t e r a t u r e . I n B r i t i s h C o l u m b i a , R o b i n s o n a n d C l a r k e (1980) , a p h y s i c i a n a n d a n u r s e , s t a t e t h a t a n e s s e n t i a l c o m p o n e n t o f f a m i l y c e n t e r e d c a r e i s t h e s u p p o r t o f p a r e n t s i n t h e i r c h a n g i n g r o l e s a n d t h e p r o v i s i o n o f h e a l t h e d u c a t i o n , d e m a n d i n g a h i g h l e v e l o f p a r e n t p a r t i c i p a t i o n i n t h e c a r e o f a h o s p i t a l i z e d c h i l d ( R o b i n s o n a n d C l a r k e , 1 9 8 0 , p . 6 5 ) . H o w e v e r , t h e y d o n o t s p e c i f y how n u r s e s c a n i n v o l v e p a r e n t s i n t h e c a r e o f t h e i r i n f a n t i n a s p e c i a l c a r e n u r s e r y . The s u c c e s s o f f a m i l y c e n t e r e d c a r e i s d e p e n d e n t u p o n c o l l a b o r a t i o n b e t w e e n n u r s e s a n d f a m i l i e s . 5 1 . 3 P r o b l e m o f P r a c t i c e F r e q u e n t l y , n u r s e s • a r e r e l u c t a n t t o e n c o u r a g e m u c h p a r e n t a l p a r t i c i p a t i o n . The c a r e o f p r e t e r m i n f a n t s r e q u i r e s e x p e r t k n o w l e d g e . The l a b i l e c o n d i t i o n o f a p r e t e r m b a b y r e q u i r e s c o n s t a n t m o n i t o r i n g o f h i s / h e r r e s p o n s e s t o t h e e n v i r o n m e n t . To p r o m o t e g r o w t h a n d w e l l b e i n g , t h e n u r s e i s r e s p o n s i b l e f o r p r o v i d i n g a n e u t r a l t h e r m a l e n v i r o n m e n t w h i c h i s t h e o p t i m u m e n v i r o n m e n t a l t e m p e r a t u r e a t w h i c h m e t a b o l i c h e a t p r o d u c t i o n a n d t h u s o x y g e n c o n s u m p t i o n a r e m i n i m a l ( S h e l d o n , 1 9 8 0 , p . 287) . T h e s e b a b i e s r e q u i r e s t r i c t d a i l y c a l o r i c a n d f l u i d r e q u i r e m e n t s r e c o m m e n d e d b y t h e p h y s i c i a n a n d i m p l e m e n t e d b y t h e n u r s i n g s t a f f . P r e t e r m b a b i e s a r e v e r y s u s c e p t i b l e t o i n f e c t i o n a n d n u r s e s h a v e t o a d h e r e t o i n f e c t i o n c o n t r o l p o l i c i e s . T h e y a r e a l s o r e s p o n s i b l e f o r t e a c h i n g t h e s e p o l i c i e s t o a l l v i s i t o r s . P r e m a t u r e n e w b o r n s r e q u i r e m i n i m a l h a n d l i n g t o e n s u r e t h a t a l l o f t h e i r e n e r g y i s c o n c e n t r a t e d i n m a i n t a i n i n g v i t a l b o d y f u n c t i o n s a n d n o t d i s s i p a t e d i n i n t e r a c t i o n . M a n y n u r s e s d e v e l o p r e l a t i o n s h i p s w i t h t h e b a b i e s f o r whom t h e y a r e c a r i n g a n d f e e l v e r y p r o t e c t i v e t o w a r d s t h e m . S i n c e p a r e n t s s p e n d m o r e t i m e w i t h t h e n u r s i n g s t a f f t h a n a n y o t h e r h e a l t h c a r e w o r k e r when v i s i t i n g t h e i r n e w b o r n s i n h o s p i t a l , n u r s e s a r e i n a p r i n c i p a l p o s i t i o n t o e n c o u r a g e 6 p a r e n t s t o p a r t i c i p a t e i n t h e c a r e o f t h e i r baby. However, t h e e m o t i o n a l impact o f a p r e t e r m b i r t h upon p a r e n t s may r e s u l t i n many res p o n s e s such as g u i l t , anger, h o s t i l i t y , shock, g r i e f , a n x i e t y or d e p r e s s i o n and t h e s e f e e l i n g s may be d i r e c t e d a t t h e n u r s i n g s t a f f o r towards one a n o t h e r . Nurses may have l i t t l e t i m e o r e x p e r t i s e t o cope w i t h p a r e n t s ' r e s p o n s e s , overcome t h e s e r e a c t i o n s and encourage p a r t i c i p a t i o n i n c a r e . The s o c i a l i z a t i o n o f n u r s e s i n t h e s e s e t t i n g s f u r t h e r e x a c e r b a t e s t h e problem. S t u d e n t s i n u n d e r g r a d u a t e n u r s i n g programs a r e not r e q u i r e d t o have n e o n a t a l i n t e n s i v e c a r e e x p e r i e n c e d u r i n g c l i n i c a l c o u r s e s so t h e i m p l e m e n t a t i o n o f f a m i l y c e n t e r e d c a r e i n t h i s s e t t i n g i s u s u a l l y l e a r n e d on t h e j o b , u n l e s s n u r s e s have had f u r t h e r s p e c i f i c e d u c a t i o n . H o s p i t a l o r i e n t a t i o n programs c o n c e n t r a t e upon t e c h n i c a l s k i l l s t h a t n u r s e s r e q u i r e f o r p r a c t i c e r a t h e r t h a n p s y c h o l o g i c a l s k i l l s . Nurses are a l s o i n f l u e n c e d by t h e i r p e e r s and l e a r n t o i n t e r a c t w i t h p a r e n t s by o b s e r v a t i o n o f how o t h e r n u r s e s i n t h e u n i t i n v o l v e p a r e n t s i n t h e c a r e o f newborns. A s p e c t s o f c a r e i n which p a r e n t s can p a r t i c i p a t e i s dependent upon t h e degree o f p r e m a t u r i t y . Each i n f a n t r e q u i r e s f o o d which may be g i v e n i n t r a v e n o u s l y o r by gavage i f he/she cannot 7 t o l e r a t e b r e a s t o r b o t t l e f e e d i n g . G a v a g e f e e d i n g i s a t u b e i n s e r t e d i n t o t h e s t o m a c h v i a t h e m o u t h o r n a r e s a n d f o o d i s i n t r o d u c e d f r o m a s y r i n g e a t t a c h e d t o t h e t u b e u s i n g g r a v i t a t i o n a l f o r c e . The b a b y a l s o n e e d s t o b e b a t h e d a n d d r e s s e d . Some n e w b o r n s d e v e l o p h y p e r b i l i r u b i n e m i a a n d r e q u i r e p h o t o t h e r a p y . A l l n e o n a t e s n e e d s t i m u l a t i o n f o r g r o w t h a n d d e v e l o p m e n t . T h e r e a r e many t i m e s when p a r e n t s r e q u i r e c o u n s e l l i n g r e g a r d i n g t h e c o n d i t i o n a n d r e s p o n s e s o f t h e i r b a b y . The t y p e o f p a r e n t a l p a r t i c i p a t i o n i n t h e a b o v e a c t i v i t i e s i s d e p e n d e n t o n t h e i d e a s a n d a c t i o n s o f t h e s t a f f i n t h e s p e c i a l c a r e n u r s e r y . 1 . 4 I m p o r t a n c e o f t h e P r o b l e m T h i s s t u d y , u n d e r s t a n d i n g n u r s e s ' p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n c a r e , w o u l d b e o f v a l u e t o t h e d e v e l o p m e n t o f i m p r o v e d n u r s i n g c a r e . A s n e o n a t a l n u r s e s m e e t a n d i n t e r a c t w i t h p a r e n t s t h e y d e v e l o p p e r s p e c t i v e s c o n c e r n i n g how t o e n c o u r a g e p a r e n t a l p a r t i c i p a t i o n i n c a r e ( B e c k e r , e t a l , 1 9 6 1 , p . 34) . D e v e l o p m e n t o f t h e p e r s p e c t i v e s w i l l b e e x p l o r e d i n r e l a t i o n t o t h e i n s t i t u t i o n a l s e t t i n g i n w h i c h t h e n u r s i n g s t a f f a r e i n v o l v i n g p a r e n t s i n t h e c a r e o f t h e i r b a b y . I n t h e l i g h t o f t h e i n v e s t i g a t i o n , c u r r e n t p o l i c i e s c o u l d b e r e v i s e d t o t a k e i n t o a c c o u n t t h e p e r s p e c t i v e s o f t h o s e n u r s e s who a r e c u r r e n t l y 8 w o r k i n g i n t h e u n i t , s u c h c h a n g e s may l e a d t o new a p p r o a c h e s t o p a r e n t a l p a r t i c i p a t i o n , a n d e n c o u r a g e i m p r o v e d c a r e f o r p r e t e r m b a b i e s . I n a d d i t i o n , t h e s e c h a n g e s may i m p r o v e t h e s e t t i n g f o r t h e t r a i n i n g o f new n u r s e s . 1 . 5 S t a t e m e n t o f t h e R e s e a r c h Q u e s t i o n The p u r p o s e o f t h e p r e s e n t s t u d y i s t o d e s c r i b e p e r s p e c t i v e s o f n u r s e s t o w a r d p a r e n t a l p a r t i c i p a t i o n i n t h e c a r e o f p r e t e r m i n f a n t s i n a n e o n a t a l i n t e n s i v e c a r e u n i t , o r s p e c i a l c a r e n u r s e r y , s p e c i f i c a l l y , t h e q u e s t i o n s t o w h i c h t h i s s t u d y a r e a d d r e s s e d a r e : 1 . What a r e s p e c i a l c a r e n u r s e s ' p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n t h e c a r e o f t h e i r b a b y i n r e l a t i o n t o t h e f o l l o w i n g a c t i v i t i e s : f e e d i n g , b a t h i n g , d r e s s i n g , p h o t o t h e r a p y , p a r e n t i n f a n t i n t e r a c t i o n a n d p a r e n t a l c o u n s e l l i n g ? 2 . I s t h e r e a r e l a t i o n s h i p b e t w e e n t h e d e v e l o p m e n t o f n u r s e s ' p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n c a r e a n d : a . a c c o u n t a b i l i t y , w o r k l o a d a n d r e s o u r s e s i n t h e w o r k s e t t i n g ? b . t h e p r o f e s s i o n a l a n d p e r s o n a l c h a r a c t e r i s t i c s o f i n d i v i d u a l n u r s e s w i t h r e s p e c t t o a g e , p a r e n t a l s t a t u s a n d l e v e l o f n u r s i n g e d u c a t i o n . 9 1 . 6 D e f i n i t i o n o f T e r m s a . F a m i l y c e n t e r e d c a r e - a n o p e n m u l t i d i m e n s i o n a l s y s t e m o f h e a l t h m a n a g e m e n t w h i c h a c k n o w l e d g e s t h e i n s e p a r a b i l i t y o f t h e i n d i v i d u a l f r o m h i s / h e r f a m i l y a n d e n v i r o n m e n t a n d w h i c h e f f e c t i v e l y u t i l i z e s t h e c o m p l i m e n t a r y s k i l l s o f a l l members o f t h e h e a l t h t e a m , i n c l u d i n g t h e c l i e n t a n d h i s / h e r f a m i l y . b . N e o n a t a l p e r i o d - f r o m b i r t h t o t h e t w e n t y - e i g h t h d a y o f l i f e . c . P a r e n t a l p a r t i c i p a t i o n - p a r e n t p e r f o r m a n c e o f a c t i v i t i e s i n t h e c a r e o f h i s / h e r h o s p i t a l i z e d n e o n a t e . d . P e r s p e c t i v e - a c o - o r d i n a t e d s e t o f i d e a d a n d a c t i o n s a p e r s o n u s e s i n d e a l i n g w i t h some p r o b l e m a t i c a l s i t u a t i o n . I t r e f e r s t o a p e r s o n ' s o r d i n a r y way o f t h i n k i n g , f e e l i n g a b o u t a n d a c t i n g i n s u c h a s i t u a t i o n . e . T e r t i a r y l e v e l n e o n a t a l n u r s e r y - a c e n t e r p r o v i d i n g c a r e f o r c r i t i c a l l y i l l b a b i e s . f . S e c o n d a r y l e v e l n e o n a t a l n u r s e r y - a c e n t e r p r o v i d i n g c a r e f o r b a b i e s who r e q u i r e s p e c i a l c a r e . 1 . 7 L i m i t a t i o n s o f t h e s t u d y T h e s c o p e o f t h i s s t u d y i s l i m i t e d t o r e g i s t e r e d n u r s e s e m p l o y e d i n o n e s e c o n d a r y l e v e l s p e c i a l c a r e n u r s e r y . T h e s e n u r s e s h a v e l i m i t e d e x p o s u r e t o p a r e n t s o f t e r t i a r y b a b i e s a n d t h e m e a n i n g 10 b . N e o n a t a l p e r i o d - f r o m b i r t h t o t h e t w e n t y - e i g h t h d a y o f l i f e . c . P a r e n t a l p a r t i c i p a t i o n - p a r e n t p e r f o r m a n c e o f a c t i v i t i e s i n t h e c a r e o f h i s / h e r h o s p i t a l i z e d n e o n a t e . d . P e r s p e c t i v e - a c o - o r d i n a t e d s e t o f i d e a d a n d a c t i o n s a p e r s o n u s e s i n d e a l i n g w i t h some p r o b l e m a t i c a l s i t u a t i o n . I t r e f e r s t o a p e r s o n ' s o r d i n a r y way o f t h i n k i n g , f e e l i n g a b o u t a n d a c t i n g i n s u c h a s i t u a t i o n . e . T e r t i a r y l e v e l n e o n a t a l n u r s e r y - a c e n t e r p r o v i d i n g c a r e f o r c r i t i c a l l y i l l b a b i e s . f . S e c o n d a r y l e v e l n e o n a t a l n u r s e r y - a c e n t e r p r o v i d i n g c a r e f o r b a b i e s who r e q u i r e s p e c i a l c a r e . 1.7 L i m i t a t i o n s o f t h e s t u d y T h e s c o p e o f t h i s s t u d y i s l i m i t e d t o r e g i s t e r e d n u r s e s e m p l o y e d i n o n e s e c o n d a r y l e v e l s p e c i a l c a r e n u r s e r y . T h e s e n u r s e s h a v e l i m i t e d e x p o s u r e t o p a r e n t s o f t e r t i a r y b a b i e s a n d t h e m e a n i n g t h i s h a s i n t h e w o r k p l a c e . The s t u d y c o n c e n t r a t e s u p o n p r e t e r m i n f a n t s , n o t a l l t h e n e o n a t e s r e q u i r i n g s p e c i a l c a r e , e . g . b a b i e s w i t h c o n g e n i t a l a n o m a l i e s o r t h o s e who r e q u i r e s u r g i c a l i n t e r v e n t i o n s . 11 C H A P T E R I I L I T E R A T U R E R E V I E W 2.1 I n t o d u c t i o n The l i t e r a t u r e r e v i e w e d f o r t h i s s t u d y i s d i v i d e d i n t o t h e f o l l o w i n g a r e a s : A . L i t e r a t u r e a d v o c a t i n g f a m i l y c e n t e r e d c a r e a n d p a r e n t p a r t i c i p a t i o n B . L i t e r a t u r e e x a m i n i n g t h e r a c t i c e o f f a m i l y c e n t e r e d c a r e C . The p r o c e s s o f c h a n g e D . N u r s e s p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n c a r e T h e s e a r e a s r e p r e s e n t t h e e v o l u t i o n o f t h e c o n c e p t o f f a m i l y c e n t e r e d c a r e a n d how p a r e n t s b e c a m e i n c l u d e d i n c a r e b y n u r s e s . S t u d i e s o f how n u r s e s i m p l e m e n t p a r e n t p a r t i c i p a t i o n i n s p e c i a l c a r e n u r s e r i e s a n d f a c t o r s t h a t i n f l u e n c e t h i s p r o c e s s a r e a d d r e s s e d . 12 2.2 L i t e r a t u r e A d v o c a t i n g F a m i l y C e n t e r e d C a r e a n d P a r e n t P a r t i c i p a t i o n F a m i l y c e n t e r e d c a r e i s a d v o c a t e d i n m a t e r n i t y u n i t s b y t h e f e d e r a l M i n i s t r y o f N a t i o n a l H e a l t h a n d W e l f a r e i n C a n a d a . T h i s p o s i t i o n was t a k e n f o r r e a s o n s o f b a s i c h u m a n i t a r i a n i s m a s w e l l a s g e n e r a l c o n c e r n s a b o u t t h e i n c r e a s e i n t h e home b i r t h m o v e m e n t w h i c h h a s i t s r o o t s i n c o n s u m e r d i s s a t i s f a c t i o n ( F a m i l y C e n t e r e d M a t e r n i t y a n d N e w b o r n C a r e , 1986, p . 3 ) . T h i s d o c u m e n t s t a t e s t h a t h e a l t h p r o f e s s i o n a l s a n d p a r e n t s h a v e s i m i l a r n e e d s a n d o b j e c t i v e s f o r c h i l d b i r t h b u t t h e e m p h a s i s c a n b e q u i t e d i f f e r e n t . P a r e n t s a r e c o n c e r n e d w i t h t h e q u a l i t y a n d u n i q u e n e s s o f t h e i r p a r t i c u l a r b i r t h e x p e r i e n c e . P o f e s s i o n a l , w h i l e r e c o g n i z i n g t h a t e a c h b i r t h e x p e r i e n c e i s d i f f e r e n t , a r e p r i m a r i l y c o n c e r n e d w i t h t h e s a f e t y o f t h e m o t h e r a n d t h e n e w b o r n . The f a c t t h a t t h e a g e n d a s o f t h e t w o g r o u p s - p a r e n t s a n d p r o f e s s i o n a l - a r e d i f f e r e n t c a n p r e s e n t r e a l p r o b l e m s a n d may l e a d t o c o n f l i c t . The c h a l l e n g e t o b o t h p r o f e s s i o n a l s a n d p a r e n t s i s t o r e c o g n i z e t h e p r i o r i t e s o f t h e o t h e r a n d t o make c o n c i l i a t i o n s i n a way t h a t p e r m i t s f u r t h e r d e c r e a s e i n p e r i n a t a l m o r t a l i t y a n d m o r b i d i t y a l o n g w i t h i n c r e a s e d c o n s u m e r s a t i s f a c t i o n . The concept of f a m i l y c e n t e r e d m a t e r n i t y care i s c e n t r a l t o meeting the needs of everyone connected with the c h i l d b e a r i n g experience ( I n t e r n a t i o n a l Task Force on the H e a l t h of Women and C h i l d r e n , 1981, p. 1; Post, 1981, p. 6). When the p r i n c i p l e s of t h i s p h i l o s o p y are a p p l i e d i t i s assumed t h a t the h o s p i t a l w i l l welcome parents, and, b a r r i n g unforeen problems, w i l l a l l o w maximum f l e x i b i l i t y and the freedom of cho i c e t o the f a m i l y (Family Centered M a t e r n i t y and Newborn  Care, 1986, p.3) . The b i r t h of a preterm i n f a n t i s one of the unforseen problems and the emphasis on f a m i l y c e n t e r e d care i n t h i s document mainly a p p l i e s f o r parents of a w e l l newborn. P y c h o l o g i s t , David Kaplan (1980), f e e l s t h a t t h e r e are f o u r major p s y c h o l o g o c a l t a s k s f o r the parent of a preterm i n f a n t . One i s p r e p a r i n g f o r the p o s s i b l e l o s s of an i n f a n t . Second i s the acknowledgement of f a i l u r e t o d e l i v e r a term i n f a n t . T h i r d i s the resumption of the process of r e l a t i n g t o the i n f a n t which has been t e m p o r t a r i l y i n t e r r u p t e d . F i n a l l y , he/she must develop an understanding t h a t the preterm i n f a n t ' s s p e c i a l needs are only temporary (Kaplan, 1960, p. 539) . The s p e c i a l care nursery nurses' r o l e i s t o a s s i s t the mother and f a t h e r t o accomplish these t a s k s by i n f o r m i n g them about p r e m a t u r i t y and encouraging them t o p a r t i c i p a t e i n care (Oehler, 1981, p. 14 140) . Mercer (1977), a nurse, has o u t l i n e d f o u r areas t h a t p l a c e a parent at r i s k when a baby i s born - when the i n f a n t has a d e f e c t , when the mother experiences a h e a l t h t h r e a t , when the parents are immature and, f i n a l l y , when the i n f a n t i s born prematurely. She suggests t h a t n u r s i n g care f o r parents of a premature i n f a n t i n c l u d e s a t t e n d i n g t o emotional, c o g n i t i v e and s o c i a l needs as w e l l as f a c i l i t a t i n g parent c h i l d acquaintance and attachment, she s t a t e s t h a t i f the i n f a n t ' s c o n d i t i o n i s such t h a t the mother can p a r t i c i p a t e i n any c a r e t a k i n g a c t i v i t i e s such as d i a p e r changing or f e e d i n g , an a c t i v i t y s hould be chosen i n which the mother w i l l be sure t o succeed. F a t h e r s may be the f i r s t t o attempt a c a r e t a k i n g a c t i v i t y while the mother may observe f o r a few times b e f o r e she wishes t o attempt t o begin g i v i n g care (Mercer, p. 122). Beaton (1984), a nurse, a l s o s t a t e s t h a t parents should be a c t i v e l y i n v o l v e d i n c a r i n g f o r t h e i r c h i l d i n order t o develop c o n f i d e n c e i n t h e i r p a r e n t i n g a c t i v i t i e s , she says -t h a t each neonatal i n t e n s i v e care u n i t i s unique and what works w e l l i n one u n i t i s i n a p p r o p r i a t e i n others and t h a t s t a f f should be f l e x i b l e and not r e l y upon s t a n d a r d i z e d 15 n u r s i n g care p l a n s (Beaton, 1984, p.177). Primary n u r s i n g i s advocated as one way t o support f a m i l i e s i n neonatal i n t e n s i v e care u n i t s (Thornton, 1984, p. 135) . A primary nurse i s accountable f o r , and i n c o n t r o l of, the ba b i e s ' n u r s i n g c a r e . She assesses at what p o i n t the parents are ready t o p a r t i c i p a t e i n more complicated care f o r t h e i r c h i l d and becomes the primary source of i n f o r m a t i o n . There i s a problem with t h i s system as the parents may f e e l j e a l o u s because they see the nurse as assuming the pa r e n t s ' r o l e , o r . co n v e r s e l y , become o v e r l y dependent upon the primary nurse and may l o s e c o n f i d e n c e when she i s not present (Thornton, 1984, p. 136). 2.3 L i t e r a t u r e Examining the P r a c t i c e of Family Centered Care There i s a l a c k of r e s e a r c h i n t o f a c t o r s i n f l u e n c i n g the p r a c t i c e of f a m i l y c e n t e r e d c a r e . P o r t e r (1979), a nurse, conducted a c o r r e l a t i o n study, u s i n g q u e s t i o n n a i r e s , t o assess the i n f l u e n c e of h e a l t h care workers' (medical and nursing) r o l e c o n c e p t i o n and t h e i r o r i e n t a t i o n (mental acceptance) t o f a m i l y c e n t e r e d c a r e . She determined t h a t e d u c a t i o n a l p r e p a r a t i o n was a s t r o n g p r e d i c t o r i n t h a t the h i g h e r the l e v e l of n u r s i n g of p r e p a r a t i o n , the h i g h e r the f a m i l y centered orientation. This study did not provide any empirical evidence of factors that influence the behavior of nurses i n the c l i n i c a l s etting when implementing family centered care. Seidl and P i l l i t t e r i (1967) developed a parent p a r t i c i p a t i o n attitude scale (P.P.S.A.) for measuring nurses' attitudes toward parental p a r t i c i p a t i o n i n care. Two hundred and t h i r t y one nurse p a r t i c i p a t e d i n the i n i t i a l production t o o l . Seidl (1969) l a t e r reported on some of the factors influencing these nurse' attitudes toward parental p a r t i c i a t i o n . He found that nurses with a higher s t a f f position, higher l e v e l of nursing education, or who had a c h i l d at home had a more accepting attitude. G i l l (1985), i n a nursing doctoral d i s s e r t a t i o n , used the P.P.S.A. scale to measure p e d i a t r i c and neonatal nurses' attitudes toward parental p a r t i c i p a t i o n i n care i n a l l of the units i n one c i t y i n the United States and her results were sim i l a r to those of Seidl and P i l l i t t e r i . The twenty four item questionnaire did not explore underlying responses to factors which on a day to day basis may influence nurses' attitudes towards parental p a r t i c i p a t i o n i n care. Klaus and Kennell (1976), pediatricians who pioneered the concept of maternal-infant bonding, encouraged health professionals to permit the mother to care for her h o s p i t a l i z e d i n f a n t e n a b l i n g her t o be c o n f i d e n t when c a r i n g f o r the i n f a n t at home Klaus and K e n n e l l , 1976, p. 122) . They conducted a f e a s i b i l i t y study p e r m i t t i n g the mothers t o remain i n h o s p i t a l with t h e i r babies while they assumeed a c a r e t a k i n g r o l e . They r e p o r t e d t h a t t h e r e was d i f f i c u l t y d e f i n i n g the r o l e of the nurse and the mother as t h e r e were t u s s l e s over who made d e c i s i o n s r e g a r d i n g the care of the baby (Klaus and Ke n n e l l , 1976, p. 135) . There were no recommendations f o r r e s o l v i n g these d i f f i c u l t i e s . A t t i t u d e surveys i n d i c a t e a r e l u c t a n c e by nurses t o encourage p a r e n t a l p a r t i c i p a t i o n i n care ( G i l l , 1985; M i l l e r . 1979; P o r t e r , 1979; S e i d l , 1969) . T h i s r e l u c t a n c e i s r e l a t e d t o e a s i l y measured s t r u c t u r a l v a r i b l e s such as age, educa t i o n and p a r e n t a l s t a t u s . However, these v a r i b l e s are d i f f i c u l t t o change except through r e c r u i t m e n t , as t h e r e i s a c u r r e n t n u r s i n g shortage, which i s i n c r e a s i n g annually, i t i s not always p o s s i b l e t o h i r e nurses who have f u r t h e r education, are parents and of a s p e c i f i c age group. 2.4 The Process of Change In the past g e n e r a t i o n the implementation of f a m i l y c e n t e r e d care has r e q u i r e d a change i n p r a c t i c e f o r neonatal nurses. 18 Understanding the meaning of change f o r p a r t i c i p a n t s i s e s s e n t i a l i n understanding the change p r o c e s s . A c c o r d i n g t o M a r r i s (1975) i n Loss and Change, a l l r e a l change i n v o l v e s l o s s , a n x i e t y and s t r u g g l e and i f t h i s i s not r e c o g n i z e d important aspects of change may be i g n o r e d or m i s i n t e r p r e t e d . F u l l a n (1982) i n The Meaning of E d u c a t i o n a l Change d e s c r i b e s what i s meant by change i n p r a c t i c e i n s u b j e c t i v e and o b j e c t i v e terms. The d a i l y s u b j e c t i v e r e a l i t y of neonatal nurses implementing f a m i l y c e n t e r e d care has not been d e s c r i b e d i n n u r s i n g l i t e r a t u r e . F u l l a n b e l i e v e s t h a t i t i s p o s s i b l e t o c l a r i f y the meaning of change by i d e n t i f i n g and d e s c r i b i n g i t s main separate dimensions ( F u l l a n , 1982, p. 29). Therefore, the r e l u c t a n c e of nurses may be understood by knowing the meaning t h a t f a m i l y c e n t e r e d care has f o r them. F u l l a n s t a t e s t h a t t h e r e are t h r e e components or dimensions at stake when implementing any new e d u c a t i o n a l program or p o l i c y ( F u l l a n , 1982, p.30). a. The p o s s i b l e use of new or r e v i s e d m a t e r i a l s b. The p o s s i b l e use of new t e a c h i n g approaches c. The p o s s i b l e a l t e r a c t i o n s of b e l i e f An i n d i v i d u a l may implement none, one, two or a l l of these dimensions. To understand the implementation of f a m i l y 19 c e n t e r e d c a r e f r o m a n e o n a t a l n u r s e s ' p e r s p e c t i v e , t h e t h i r d d i m e n s i o n w i l l b e u s e f u l t o d e s c r i b e why some n u r s e s a c c e p t a n i n n o v a t i o n , why some a s p e c t s a r e i m p l e m e n t e d a n d why o t h e r s a r e n o t . A n a n a l y s i s o f n u r s e s ' p e r s p e c t i v e s o f f a m i l y c e n t e r e d c a r e w o u l d e n a b l e n u r s i n g e d u c a t o r s t o d e v e l o p s t a r a t e g i e s t o d e m o n s t r a t e d i f f e r e n c e s i n n u r s i n g p r a c t i c e a n d how t h i s may i m p a c t o n p a r e n t s . 2 . 5 N u r s e s ' P e r s p e c t i v e s o f P a r e n t a l P a r t i c i p a t i o n i n C a r e T h e c o n e p t o f p e r s p e c t i v e u s e d i n t h i s s t u d y i s d e v e l o p e d b y B e c k e r , G r e e r , H u g h e s a n d S t r a u s (1961) i n B o y s i n W h i t e . T h e y d e s c r i b e t h e t e r m p e r s p e c t i v e a s a c o - o r d i n a t e d s e t o f i d e a s a n d a c t i o n s a p e r s o n u s e s i n d e a l i n g w i t h some p r o b l e m a t i c a l s i t u a t i o n . I t r e f e r s t o a p e r s o n ' s o r d i n a r y way o f t h i n k i n g , f e e l i n g a b o u t a n d a c t i n g i n s u c h a s i t u a t i o n ( B e c k e r , e t a l . , 1 9 6 1 , p . 3 4 ) . P e r s p e c t i v e s a r i s e when p e o p l e h a v e c h o i c e s . A n e o n a t a l n u r s e d o e s n o t h a v e a n y s p e c i f i c g u i d e l i n e s w h e n e n c o u r a g i n g p a r e n t s t o p a r t i c i p a t e i n c a r e a s o p p o s e d t o w t i t t e n p o l i c i e s a n d p r o c e d u r e s t h a t g u i d e t e c h n i c a l s k i l l s . The n u r s e , t h e r e f o r e , h a s a c h o i c e o f how m u c h o r how l i t t l e h e / s h e w i l l p e r m i t p a r e n t s t o p r o v i d e c a r e f o r t h e i r c h i l d . B e c k e r s u g g e s t s t h a t i f a p a r t i c u l a r s i t u a t i o n r e c u r s f r e q u e n t l y , t h e p e r s p e c t i v e w i l l p r o b a b l y b e c o m e a n 20 e s t a b l i s h e d p a r t of a person's d e a l i n g with the world (Becker, et a l . , 1961, p. 35). Neonatal nurses, t h e r e f o r e , would develop a p e r s p e c t i v e of p a r e n t a l p a r t i c i p a t i o n i n the care of a preterm i n f a n t as they g a i n experience i n p a r t i c u l a r i n s t i t u t i o n a l c o n t e x t s . Becker goes on t o d e s c r i b e a group p e r s p e c t i v e a r i s i n g when people see themselves i n the same boat and have an o p p o r t u n i t y to i n t e r a c t with r e f e r e n c e t o t h e i r problem (Becker, et a l . , 1961, p. 35). A nurse's p e r s p e c t i v e w i l l g a i n s t r e n g t h when she sees i t as p a r t of a common p e r c e p t i o n shared by her c o l l e g u e s . To formulate the content of nurses' p e r s p e c t i v e s the work a c t i v i t i e s of f e e d i n g , bathing, d r e s s i n g , i n t e r a c t i o n and parent c o n s e l l i n g are used t o a s c e r t a i n how nurses i n v o l v e parents i n each a c t i v i t y and the ideas and a c t i o n s group members apply i n d e a l i n g with the s i t u a t i o n . When the a c t i v i t y has been d e s c r i b e d then c e r t a i n c h a r a c t e r i s t i c s , frequency, range and c o l l e c t i v e c h a r a c t e r i s t i c s can be e s t a b l i s h e d t o assess t o what extent i t i s the customary way f o r nureses t o d e a l with the problem i t r e f e r s t o (Becker, et a l . , 1961 p. 39) . 2.6 C o n c l u s i o n Family c e n t e r e d care i s viewed as a g u i d i n g p h i l o s o p h y f o r the d e l i v e r y of m a t e r n i t y h e a l t h care and p a r e n t a l p a r t i c i p a t i o n i s an i n t e g r a l p a r t of t h i s c a r e . The b i r t h of a preterm i n f a n t i s a c r i s i s f o r parents and d u r i n g t h i s time h e a l t h care p r o f e s s i o n a l s have t o adapt t o the s p e c i a l needs of these f a m i l i e s . Nurses are the major p r o v i d o r s of care and t h e i r approach to p a r e n t a l p a r t i c i p a t i o n i n care i n f l u e n c e s p r a c t i c e . Except f o r s t r u c t u r a l v a r i a b l e s , f a c t o r s t h a t i n f l u e n c e nurses' p e r s p e c t i v e s of p a r e n t a l p a r t i c i p [ a t i o n i n care have not been i d e n t i f i e d i n n u r s i n g l i t e r a t u r e , i t would be u s e f u l to study how nurses p e r c e i v e t h e i r r o l e i n p a r e n t a l p a r t i c i a p t i o n i n care and to d e s c r i b e how the i n s t i t u t i o n a l s e t t i n g a f f e c t s t h i s p r o c e s s . 22 CHAPTER III METHODOLOGY 3.1 Introduction This chapter w i l l discuss the research design, the description of the sett i n g and the sample. The development and p i l o t i n g of the interviews w i l l also be explained. 3.2 Choice of Methodology To explore the meaning parental p a r t i c i p a t i o n i n care has for neonatal nurses interviews were conducted with f u l l time s t a f f members i n a secondary l e v e l special care nursery. A qu a l i t a t i v e anaylsis was conducted of the interview data. The use of semi-structured interviews allowed nurses ideas to be c l a r i f i e d and meanings to be checked. In a semi-structured interview the interviewer w i l l often f i n d that interviewees w i l l raise important issues not contained i n the schedule, or even summarize entire sections of the schedule i n one long series of statements (Denzen, 1978, p. 115). This i s important to capture the meaning of family centered care for nurses and 23 how they i n d i v i d u a l l y a s s i s t parents t o p a r t i c i p a t e i n the care of t h e i r baby. Observations were c o n s i d e r e d . However, s i n c e I was and continue t o be employed i n an e d u c a t i o n a l r o l e i n t h i s u n i t the s t a f f may not have e x h i b i t e d t h e i r u s u a l work h a b i t s i f I had been an observer i n the u n i t and may have thought t h a t I was e v a l u a t i n g t h e i r work performance. Data on the age, p a r e n t a l s t a t u s and e d u c a t i o n a l s t a t u s of the nurses was gathered t o see i f they were r e l a t e d t o nurses' p e r s p e c t i v e s of p a r e n t a l p a r t i c i p a t i o n . The processes and events meaningful t o the s u b j e c t s were c l a s s i f i e d and r e c l a s s i f i e d and r e l a t e d t o t h e i r p e r s p e c t i v e . F a c t o r s t h a t enhance or d e t r a c t from i n v o l v i n g parents were sought. To acheive t h i s the data were ana l y s e d u s i n g the stages of i n q u i r y o u t l i n e d by Denzen (1978). The f i r s t step i s t o determine whether new i n s i g h t s may occur. The next step i s deduction when c r i t i c a l concepts are d e f i n e d . F i n a l l y , i n d u c t i o n t o i d e n t i f y p o s s i b l e r e l a t i o n s h i p s between f a c t o r s and p e r s p e c t i v e s . 3.3 D e s c r i p t i o n of S e t t i n g and Sample The s e t t i n g i s a twenty f o u r bed secondary l e v e l n eonatal i n t e n s i v e care u n i t i n B r i t i s h Columbia. The M i n i s t r y of 24 He a l t h developed g u i d e l i n e s f o r the care of neonates i n 1978 when they d e s i g n a t e d primary, secondary and t e r t i a r y n u r s e r i e s i n the p r o v i n c e . Preterm i n f a n t s are cared f o r i n secondary u n i t s u n l e s s they are h i g h r i s k and r e q u i r e r e f e r r a l t o a t e r t i a r y c e n t e r f o r treatment. In June, 1988 the l e v e l of care i n t h i s p a r t i c u l a r u n i t where the study took p l a c e was upgraded t o o f f e r some t e r t i a r y c a r e . The nursery i s one l a r g e room which houses a l l of the neonates so nurses are i n constant c o n t a c t with one another d u r i n g working hours. The u n i t i s b r i g h t l y l i t twenty-four hours a day with am ambient temperature of e i g h t y degrees. There are constant beeping s i g n a l s i s s u i n g from the machinery which monitors the s t a t u s of the newborn; alarms sound f r e q u e n t l y from these machines when problems are d e t e c t e d . Many of the neonates are nursesd i n i s o l e t t e s while others are i n open c r i b s . The space i s crowed and i n the b u s t l e of d a i l y a c t i v i t y the nurses and pa r e n t s have l i t t l e room t o manoever around the i n f a n t s and the machinery. The u n i t has f a m i l y c e n t e r e d care p h i l o s o p h y which s t a t e s : A f a m i l y c e n t e r e d aproaach encourages parents t o p a r t i c i p a t e i n t h e i r c h i l d ' s care and thereby promote 25 h e a l t h y p a r e n t / c h i l d r e l a t i o n s h i p s . The emotional andinformative needs of each f a m i l y should be d e a l t with i n an i n d i v i d u a l way (Standards of Care Manual, 1984, p. 8) . To encourage f a m i l y c e n t e r e d care parents have v i s i t i n g p r i v e l e g e s twenty-four hours a day. Many of the babies are born by c e s a r i a n s e c t i o n and the f a t h e r u s u a l l y accompanies the p h y s i c i a n or nurse from the o p e r a t i n g room t o be with the baby when he/she i s admitted t o the nur s e r y . When the mother leaves the post o p e r a t i v e recovery area f o l l o w i n g a c e s a r i a n b i r t h she f i r s t v i s i t s the baby i n the s p e c i a l care nursery b e f o r e t r a n s f e r t o the postpartum u n i t . When i n h o s p i t a l , mothers who cannot walk from the postpartum f l o o r are brought t o the nursery t o v i s i t the baby by the n u r s i n g s t a f f i n a wheelchair. On the f i r s t v i s i t p arents are taught gowning and hand washing p r o t o c o l which i s e n f o r c e d f o r s t a f f and v i s i t o r s a l i k e . The u n i t adopted a new v i s i t i n g p r o t o c o l i n January 1988 which allows s i b l i n g s and f a m i l y members t o accompany parents i n t o the u n i t . Parents can choose who they wish t o v i s i t w ith them but are requested t o l i m i t s i b l i n g v i s i t i n g t o short p e r i o d s . There are no s p e c i f i c p o l i c i e s or procedures t h a t provde 26 g u i d e l i n e s f o r the nusres regarding p a r e n t a l p a r t i c i p a i o n i n care. The sample of nurses chosen to p a r t i c i p a t e i n t h i s study are the m a j o r i t y of f u l l time s t a f f members. I t was not p o s s i b l e to i n t e r v i e w every f u l l time s t a f f member due t o maternity leave or i l l n e s s . The u n i t i s unusual i n that i t has a very small annual t u r n over of nursing s t a f f . In many i n t e n s i v e care n u r s e r i e s there i s a high percentage of new nursing s t a f f each year. The nurses work both twelve and eigh t hours s h i f t s . C o n t i n u i t y of care i s provided when p o s s i b l e so that the nurse w i l l have the same p a t i e n t assignment during her r o t a t i o n of work. There are between f i v e and s i x nurses on duty at one time. The p a t i e n t assignment f o r each s t a f f member i s dependent on the a c u i t y of care of the newborns. A l l of the nurses are female. A l l of the p e d i a t r i c i a n s are male. A l l of the twelve nurses interviewed have at l e a s t f i v e years of experience i n neonatal nursing and are f u l l time s t a f f members. A l l have worked i n t h i s s p e c i f i c u n i t f o r two years and some f o r as long as f i f t e e n years or more. Most have taken f u r t h e r nursing e d u c a t i o n a l courses r e l a t e d t o neonatal or maternity nursing, or have obtained midwifery c r e d e n t i a l s . 27 They have a l l p a r t i c i p a t e d i n the care of preterm infants. I have been employed at t h i s agency since 197 8 and my involement with the unit has been i n an educational capacity. I was a f u l l time s t a f f member of the nursing education department for f i v e years and my major r e s p o s i b i l i t y was to provide inservice programs for the maternal c h i l d units. I am s t i l l employed by the special care nursery on a sessional basis to provide on-going educational programs. 3.3 Development and P i l o t i n g of Interviews The Director of Nursing was contacted for approval to conduct t h i s study i n her agency. A summary of the research proposal, a copy of the l e t t e r to the prospective students and a copy of the research instrument are included i n Appendix I. Upon approval of the Director of Nursing, three s t a f f members were i n v i t e d to p i l o t the interview schedule. These nurses where chosen because they had been previously employed as f u l l time s t a f f members i n the unit and are currently employed there. They are experienced s t a f f members and maintain t h e i r knowledge and s k i l l s i n neonatal nursing by frequently attending continuing nursing educational courses. Permission 28 t o tape the i n t e r v i e w was granted and the in t e r v i e w s l a s t e d about one hour. Each of the three nurses were asked t o c r i t i q u e the i n t e r v i e w immediately f o l l o w i n g the se s s i o n . They thought t h a t the questions were i n l o g i c a l order and were able t o understand each one. The in t e r v i e w s were t r a n s c r i b e d and the responses analysed t o ensure the questions e l i c i t e d an appropriate response. Some questions were combined as the same informati o n was c o l l e c t e d i n another part of the i n t e r v i e w and two questions were de l e t e d because of redundancy. When the i n t e r v i e w schedule had been r e v i s e d the subjects were contacted to request t h e i r p a r t i c i p a t i o n i n the study. F i f t e e n f u l l time s t a f f members were contacted by mail with an i n v i t a t i o n t o p a r t i c i p a t e i n t h i s study. This l e t t e r i s i n Appendix I . Three nurses d e c l i n e d to be interviewed. Each subject was contacted by phone f o r a s u i t a b l e time and place t o be interviewed. At the time of the i n t e r v i e w each of the twelve subjects were given a v e r b a l d e s c r i p t i o n of the i n t e r v i e w procedure and requested t o s i g n a consent form a l l o w i n g the i n t e r v i e w to be taped. The in t e r v e i w s took place over a two month p e r i o d . When the in t e r v i e w s were completed they were t r a n s c r i b e d and the data were so r t e d i n t o c a t e g o r i e s according t o the research questions. A f t e r f u r t h e r anaysis two 2 9 perspectives dominated. The data and the analysis are contained i n the next chapter. 30 CHAPTER IV ANALYSIS OF DATA Th i s chapter p r e s e n t s an a n a l y s i s of the i n t e r v i e w data. The f i r s t p a r t of the chapter d e a l s with the responses i n r e l a t i o n t o r e s e a r c h q u e s t i o n number one: what i s a s p e c i a l care nurse's p e r s p e c t i v e of p a r e n t a l p a r t i c i p a t i o n i n r e l a t i o n t o the f o l l o w i n g a c t i v i t i e s : f e e d i n g , b a t h i n g , d r e s s i n g , phototherapy, parent i n f a n t i n t e r a c t i o n and p a r e n t a l c o u n s e l l i n g ? The second p a r t of t h i s chapter w i l l be devoted to answering the second r e s e a r c h q u e s t i o n : i s t h e r e a r e l a t i o n s h i p between the development of a nurse's p e r s p e c t i v e of p a r e n t a l p a r t i c i p a t i o n i n care and: a. the work s e t t i n g i n the areas of a c c o u n t a b i l i t y , workload and resources? b. the p r o f e s s i o n a l and p e r s o n a l c h a r a c t e r i s t i c s of i n d i v i d u a l nurses i n the areas of n u r s i n g education, age, p a r e n t a l s t a t u s and a number of years they have 31 spent i n neonatal n u r s i n g . Two n u r s i n g p e r s p e c t i v e s i d e n t i f i e d from the i n t e r v i e w data have been t i t l e d the 'our baby' and ' t h e i r baby' p e r s p e c t i v e s . The responses of i n d i v i d u a l nurses can be seen to be c o n s i s t e n t with one of these p e r s p e c t i v e s across a range of a c t i v i t i e s . T h i s chapter w i l l analyze the extent t o which nurses with a common p e r s p e c t i v e of p a r e n t a l p a r t i c i p a t i o n i n the care of preterm neonates share p r o f e s s i o n a l and p e r s o n a l c h a r a c t e r i s t i c s . The f i r s t two s e c t i o n of t h i s chapter o u t l i n e how the two p e r s p e c t i v e s were d e f i n e d and how a recent change i n the v i s i t i n g p o l i c y of the u n i t had an impact upon the nurses i n t h i s study. RESEARCH QUESTION ONE 4.1 'Our Baby' versus ' T h e i r Baby' Nurses i n t h i s study tended t o adopt one of two p e r s p e c t i v e s of p a r e n t a l p a r t i c i p a t i o n with preterm i n f a n t s i n a s p e c i a l care nursery. The l a b e l s 'our baby ' and ' t h e i r baby' were s e l e c t e d because the s u b j e c t s used these terms i n a v a r i e t y of ways t o d e s c r i b e t h e i r p e r s p e c t i v e of p a r e n t a l p a r t i c i p a t i o n . F i v e of the nurses h e l d a f a m i l y c e n t e r e d p e r s p e c t i v e and s t a t e d t h a t the b i r t h of a preterm i n f a n t was a " c r u c i a l time 32 for the parents" (J, interview, February 14, 1988,) "and, afte r a l l , t h i s was t h e i r baby". In contrast, seven nurses had a t r a d i t i o n a l nursing perspective stressing that they were responsible for a l l aspects of care including parental p a r t i c i p a t i o n (L, interview, February 7, 1988,) "because, afte r a l l , t h i s was our baby". These labels, 'our baby' and 't h e i r baby' are not absolute. Each nurse i n the study expected to interact and involve parents i n the care of t h e i r infants on a d a i l y basis. These labels were chosen to i l l u s t r a t e the difference i n emphasis of the two nursing perspectives and an understanding of the perspectives of the two groups of nurses. The difference i n perspective became apparent i n the opening question of the interview when nurses were asked to explain what parent p a r t i c i p a t i o n meant to them. A l l of the nurses i n the ' t h e i r baby' groups stated that they f a c i l i t a t e d parent-infant attachment. On the i n i t i a l v i s i t to the nursery the parents are often overwhelmed by a l l of the technology surrounding the infant and have d i f f i c u l t y accepting that t h i s i s , i n fact, ' t h e i r baby'. One nurse said she assisted the parents i n "bonding with t h e i r baby and not the machinery" (C, interview, February 4, 1988) . She explained that her goal on 3 3 the parents' i n i t i a l v i s i t to the nursery i s to a s s i s t them to overcome t h e i r intimidation of the array of equipment attached / to the baby i n an incubator. She accomplishes t h i s by di r e c t i n g the parents' attention away from a l l of the medical technology surrounding the baby and describes p o s i t i v e things about the baby to help the parents i d e n t i f y with ' t h e i r baby'. Another nurse i n the group said that she "assists the parents to increase t h e i r self-esteem as the b i r t h of a preterm infant i s a c r i s i s s i t u a t i o n " (B, interview, February 6, 1988). Another nurse said parents "should p a r t i c i p a t e as much as possible i n care because i t i s t h e i r baby" (E, interview, February 12, 1988) . One nurse discussed the need to in d i v i d u a l i z e care as each family's needs are d i f f e r e n t (J, interview, February 14, 1988). These nurses displayed a family centered approach to care. On the other hand, the nurses i n the 'our baby' group tended to display a t r a d i t i o n a l approach to care i n the special care nursery. They l i s t e d tasks that parents could accomplish during t h e i r v i s i t to the nursery rather than a family-centered approach to care when nurses' would focus on the assessment of the needs of in d i v i d u a l family members. "The parents can touch, change pants, take the temperature" (F, 34 i n t e r v i e w , F e b r u a r y 6, 1988) . " I t i s n i c e t o see t h e baby g e t t i n g l o v e from t h e p a r e n t s as w e l l as us" s t a t e d one nu r s e (A, i n t e r v i e w , F e b r u a r y 18, 1988) . A l t h o u g h she i s q u i t e a c c e p t i n g o f p a r e n t a l v i s i t s t h i s n u r se views p a r e n t a l - i n f a n t attachment o f a secondary importance t o t h a t of h e r r e l a t i o n s h i p w i t h t h e baby. Not one o f t h e n u r s e s i n t h i s group mentioned p a r e n t / i n f a n t attachment i n r e l a t i o n t o p a r e n t a l p a r t i c i p a t i o n i n t h e s p e c i a l c a r e n u r s e r y . One a s p e c t o f f a m i l y c e n t e r e d c a r e i s i n c l u d i n g p a r e n t s i n d e c i s i o n - m a k i n g o f t h e c a r e o f t h e i r baby. I n t h e 'our baby' group o f n u r s e s almost a l l agreed t h a t p a r e n t s do not make any d e c i s i o n s about t h e c a r e o f t h e baby. "The major d e c i s i o n s a r e made by t h e n u r s i n g s t a f f " (H, i n t e r v i e w , F e b r u a r y 8, 1988) and " p a r e n t s go a l o n g w i t h what t h e nurse s u g g e s t s " (F, i n t e r v i e w , F e b r u a r y 6, 1988) were two s t a t e m e n t s from t h i s group. "The nu r s e knows b e s t " (D, i n t e r v i e w , F e b r u a r y 12, 1988) and "most p a r e n t s do not want t o be i n v o l v e d i n d e c i s i o n making because t h e y do not have t h e knowledge about t h e i n f a n t ' s c a r e " (K, i n t e r v i e w , F e b r u a r y 9, 1988) emphasizes t h e p e r s p e c t i v e o f t h i s group. T h i s group d i d not c o n s i d e r t h a t p a r e n t s c o u l d be i n v o l v e d i n some o f t h e n u r s i n g d e c i s i o n making about t h e p a r e n t i n g needs o f a neonate. 35 In c o n t r a s t t o t h e approach o f t h e 'our baby' n u r s e s , a ' t h e i r baby' n u r s e ' s p e r s p e c t i v e on i n v o l v i n g p a r e n t s i n d e c i s i o n making was "as i t i s t h e i r baby, p a r e n t s s h o u l d be i n v o l v e d i n d e c i s i o n s r e g a r d i n g c a r e " (E, i n t e r v i e w , F e b r u a r y 12, 1988) . "Nurses can d i s c u s s t h e i r d a i l y c a r e p l a n w i t h p a r e n t s and i n c l u d e t h e n i n d e c i s i o n s when t h e r e a r e changes i n t h e c o n d i t i o n o f t h e baby o r m o d i f i c a t i o n o f t r e a t m e n t " ( J , i n t e r v i e w , F e b r u a r y 14, 1988) . Most o f t h e n u r s e s i n t h i s group agreed t h a t p a r e n t s c o u l d make d e c i s i o n s about p a r e n t i n g a s p e c t s o f c a r e when t h e y a r e f a m i l i a r w i t h t h e i r baby and have been t a u g h t about t h e baby's needs. "You cannot t e a c h t h e baby t h e r e f o r e you t e a c h t h e p a r e n t s " (E, i n t e r v i e w , F e b r u a r y 12, 1988) e x p l a i n e d one nu r s e from t h e ' t h e i r baby' group. 4.2 P e r s p e c t i v e s o f Change R e g a r d i n g P a r e n t a l P a r t i c i p a t i o n i n Care. A marked d i f f e r e n c e i n p e r s p e c t i v e o f t h e two groups was seen when t h e y were asked about t h e r e c e n t change i n t h e v i s i t i n g p o l i c y o f t h e s p e c i a l c a r e n u r s e r y . Two months b e f o r e t h e i n t e r v i e w s were conducted v i s i t o r s , o t h e r t h a n p a r e n t s and 36 grandparents, were allowed t o e n t e r the u n i t and v i s i t the baby i n the company of one of the p a r e n t s . The p o l i c y s t a t e d t h a t parents can choose one f r i e n d or r e l a t i v e t o accompany then when v i s i t i n g the baby so t h a t no more than two v i s i t o r s per baby would be i n the nursery at one time. S i b l i n g s are a l s o allowed t o come and v i s i t the new baby. P r e v i o u s l y , s i b l i n g s stood behind a g l a s s window while the parent brought the baby f o r them t o see at the other s i d e of a window. The nurse was the one t o a l l o w or r e f u s e access t o v i s i t o r s t o the u n i t . The 'our baby' group r e p l i e s t o t h i s q u e s t i o n about t h i s change were almost unanimous. From t h e i r p e r s p e c t i v e the change i n the v i s i t i n g p o l i c y was a n e g a t i v e experience. "I don't l i k e i t . I agree t h a t parents should be i n v o l v e d but i t i s not r i g h t t o have c h i l d r e n i n a h o s p i t a l " (A, i n t e r v i e w , February 18, 1988) . Others were not q u i t e so outspoken, one s t a t i n g t h a t "the p o l i c y i s too l i b e r a l and c r e a t e s too many o p p o r t u n i t i e s f o r the i n t r o d u c t i o n of i n f e c t i o n " (D, i n t e r v i e w , February 7, 1988). "The nurse s t i l l c o n t r o l s v i s i t i n g and nurses and v i s i t o r s must f o l l o w the r u l e s " (F, i n t e r v i e w , February 6, 1988) . "Parents abuse the new p o l i c y and the u n i t becomes very crowded making i t d i f f i c u l t t o look 37 a f t e r our b a b i e s " (G, i n t e r v i e w , February 21, 1988) . "Kids are running around the u n i t t o u c h i n g e v e r y t h i n g when they are supposed t o have a quick v i s i t " (H, i n t e r v i e w , February 8, 1988) . One nurse i n t h i s group had experienced a s i m i l a r v i s i t i n g p o l i c y i n the u n i t where she had worked p r e v i o u s l y and d i d not f i n d any d i f f i c u l t i e s with the change (K, i n t e r v i e w , February 9, 1988) . The s u b j e c t s d i d not d i s c u s s whether t h i s change i n p o l i c y was a p o s i t i v e experience f o r the p a r e n t s . The major complaint seemed t o be t h a t these v i s i t o r s , e s p e c i a l l y s i b l i n g s , d i s r u p t e d the nurses working i n the u n i t which l e d t o a l o s s of c o n t r o l over t h e i r environment. Parents do not f o l l o w the p o l i c y and i n v i t e l o t s of people t o v i s i t at the same time, e x p l a i n e d f i v e out of the seven s u b j e c t s i n the 'our baby' group. "I don't l i k e b e i n g the mean one but I have t o " (L, i n t e r v i e w , February 9, 1988) was the r e p l y when I asked t h i s s u b j e c t how she s o l v e d the problem of too many v i s i t o r s at one time. She t e l l s the parents and v i s i t o r s they have t o leave and only two people are admitted t o v i s i t the baby at once. When I probed other nurses about the abuse of the v i s i t i n g p o l i c y they d i d admit t h a t only a 38 few parents abuse the system. "One grandmother held the c h i l d and, of course, everyone else wants to" (D, interview, February 7, 1988). When I asked how things could be improved the nurse did not know what to suggest. The 'our baby' group also suggested that other nurses i n the unit did not adhere to the v i s i t i n g p o l i c y . "Some nurses are too l i b e r a l giving information to v i s i t o r s " (D, interview, February 7, 1988) . This subject went on to explain that " v i s i t o r s show up at the door and demand entrance without the parent being there and some nurses give then information". When probed about t h i s s i t u a t i o n i t was revealed that i n one instance a v i s i t o r , who was a physician and an aunt of the baby, demanded information from the s t a f f . "Some nurses don't enforce the p o l i c y and l e t everybody i n and t h i s makes l i f e d i f f i c u l t when I have to stop t h i s " (H, interview, February 3, 1988). Two nurses stated that the p o l i c y was poorly introduced and they had no input (L, interview, February 7, 1988; H, interview, February 8, 1988). The v i s i t i n g guidelines were posted for s t a f f input before the changes was introduced. I asked each nurse i f they anticipated any circumstances when the v i s i t i n g p o l i c y could be relaxed i n i n d i v i d u a l cases but everyone i n the ' our baby' group thought there should be no 39 exceptions to the r u l e because every parent would want s i m i l a r p r i v i l e g e s and then v i s i t i n g would become u n c o n t r o l l a b l e . The parents who had a nurse from the ' t h e i r baby' group would f i n d a more t o l e r a n t p e r s p e c t i v e of the v i s i t i n g p o l i c y . T h i s group of nurses tended t o expand t h e i r focus from not only n u r s i n g p r i o r i t i e s but to the needs of s p e c i f i c f a m i l i e s . Parents should be i n c o n t r o l of v i s i t o r s . " I t was d i f f i c u l t at f i r s t but we are t r y i n g t o work i t out" (C, i n t e r v i e w , February 4, 1988) was the way one nurse d e s c r i b e d the new p o l i c y . " S i b l i n g s are no problem. I love them, they b r i g h t e n up the n u r s e r y " (B, i n t e r v i e w , February 6, 1988). Another nurse i n t h i s group s a i d t h a t she was used to t h i s system as i t was s i m i l a r t o the one at the p l a c e of her p r e v i o u s employment (E, i n t e r v i e w , February 12, 1988). "I e x p l a i n the v i s i t i n g p o l i c y t o the parents and they s e l e c t who they wish t o v i s i t , sometimes the r u l e s have t o be bent a l i t t l e i n c e r t a i n cases, such as with a baby who i s d y i n g " (J, i n t e r v i e w , February 14, 1988). When questioned about abuses of the v i s i t i n g p o l i c y t h i s group of nurses agreed t h a t parents u s u a l l y co-operate, with the odd e x c e p t i o n , and f o l l o w the g u i d e l i n e s . These nurses were p l e a s e d t h a t they d i d not have t o p o l i c e v i s i t o r s as they d i d p r e v i o u s l y . The change was 40 accepted as a p o s i t i v e step f o r parents by the ' t h e i r baby' group. P e r s p e c t i v e s r e g a r d i n g p a r e n t a l p a r t i c i p a t i o n i n the care of premature i n f a n t s of the two groups of nurses were not always so d i s t i n c t . The next s e c t i o n s w i l l c o n s i d e r the nurses' p e r s p e c t i v e s i n r e g a r d to s p e c i f i c p a r e n t a l a c t i v i t i e s i n the care of a preterm baby. 4.3 P e r s p e c t i v e of P a r e n t a l P a r t i c i p a t i o n In Infant Feeding 4.3.1 The Feeding Schedule A l l of the s u b j e c t s i n t h i s study agreed t h a t they d i s c u s s e d the i n f a n t f e e d i n g schedule with p a r e n t s . Each nurse s t a t e d t h a t a l l parents of preterm i n f a n t s shared a common concern about f e e d i n g . Once the baby i s b e i n g gavage or b o t t l e f e d the nurses d i s c u s s the times and amounts of feeds with the p a r e n t s . "We are always honest with the parents, i t works b e t t e r t h a t way" (I, i n t e r v i e w , February 12, 1988) was the comment of one of the 'our baby' group of nurses. None of the s u b j e c t s d e s c r i b e d neonatal f l u i d and c a l o r i c requirements i n d e t a i l u n l e s s the parents asked f o r s p e c i f i c d e t a i l s . "I w i l l not i n i t i a t e t e c h n i c a l t a l k u n l e s s i t i s necessary" (C, interview, February 4, 1988) stated one nurse from the 'th e i r baby' group. " I explain how much and what they are getting" (F, interview, February 6, 1988) said one subject from the 'our baby' group and she went on to say that "parents learn the nurses' terminology regarding infant n u t r i t i o n a l requirements as they become f a m i l i a r with the s t a f f and comfortable i n the unit". Discussion of s p e c i f i c d e t a i l s of infant n u t r i t i o n are not always discussed with the parents by either group of nurses unless the parents themselves i n i t i a t e the discussion and then only i n medical terminology as described by one subject above i n the 'th e i r baby' group. S t r i c t adherence to an exact feeding schedule has been replaced with demand feeding for f u l l term infants and i s gaining slow acceptance i n some special care nurseries. The baby gives cues that he/she i s hungry and i s fed at that time rather than being woken, or having to wait u n t i l the schedule dictates that i t i s time to eat. In a special care nursery physicians prescribe the exact quantity and time of each feed. As the baby improves some centers are encouraging a relaxation of a r i g i d feeding schedule and experimenting with demand feeding for preterm infants. Two responses of the 'th e i r baby' group were, f i r s t : "I do teach the parents about demand 42 f e e d i n g " (J, i n t e r v i e w , February 14, 1988) and, second: "the baby decides when to f e e d and I t e a c h the parents when to r e c o g n i z e t h i s " (E, i n t e r v i e w , February 12, 1988) . Another member of t h i s group s a i d t h a t when two of the p e d i a t r i c i a n s a l l o w demand f e e d i n g when f e e d i n g d i f f i c u l t i e s arose. The nurse d i s c u s s e d t h i s problem with the p h y s i c i a n and i t was a nurse/doctor t h i n g t o persuade the p h y s i c i a n s to a l l o w demand f e e d i n g (I, i n t e r v i e w , February 12, 1988). These nurses re c o g n i z e i n d i v i d u a l d i f f e r e n c e s i n the babies and t r y t o accommodate a more f l e x i b l e f e e d i n g schedule by s h a r i n g knowledge with the parent and n e g o t i a t i n g f o r change i n the i n f a n t s f e e d i n g schedule with the medical s t a f f . The members of the 'our baby' group d i d not mention demand f e e d i n g and were more i n c l i n e d t o adhere to a r i g i d f e e d i n g schedule f o r both the parents and the baby. 4.3.2 B o t t l e Feeding Each s u b j e c t expected a l l parents t o p a r t i c i p a t e i n b o t t l e f e e d i n g the baby. However, t h e r e were d i f f e r e n c e s i n p e r s p e c t i v e r e g a r d i n g how f l e x i b l e nurses were prepared t o be i n accommodating p a r e n t a l v i s i t s t o c o i n c i d e with the p r e s c r i b e d f e e d i n g schedule. " P h y s i c i a n s make a l l the d e c i s i o n s r e g a r d i n g i n f a n t n u t r i t i o n a n d p a r e n t s h a v e t o f i t i n t o t h e s e t f e e d i n g s c h e d u l e " ( L , i n t e r v i e w , F e b r u a r y 7, 1988), f o r e x a m p l e , s t a t e d o n e o f t h e ' o u r b a b y ' g r o u p o f s u b j e c t s . T h e n u r s e s i n t h e ' t h e i r b a b y ' g r o u p a l l s t a t e d t h a t t h e y w o u l d a l l o w t h e p a r e n t s o n e h o u r l e e w a y s o t h a t t h e p a r e n t s c o u l d b o t t l e f e e d t h e i r b a b y d u r i n g t h e v i s i t . One n u r s e i n t h e ' o u r b a b y ' g r o u p s a i d t h a t t h e y b a b y s h o u l d n o t h a v e t o w a i t i f t h e p a r e n t d o e s n o t a r r i v e a t t h e p r e s c r i b e d t i m e a n d s h e f e e d s t h e b a b y o n s c h e d u l e ( H , i n t e r v i e w , F e b r u a r y 8, 1988) . A n o t h e r s a i d i f t h e b a b i e s a r e n o t f e d o n t i m e t h i s i n t e r f e r e d w i t h t h e r e s t o f h e r w o r k i n g s c h e d u l e f o r t h e d a y a n d a l l o f t h e f e e d s w e r e b e h i n d t i m e (K , i n t e r v i e w , F e b r u a r y 9, 1988) . The d i f f e r e n c e i n t h e n u r s e s ' p e r s p e c t i v e d i d i n f l u e n c e p a r e n t a l p a r t i c i p a t i o n i n b o t t l e f e e d i n g . " B o t t l e f e e d i n g i s s o m e t h i n g p a r e n t s h a v e l i t t l e d i f f i c u l t y d o i n g " (G, i n t e r v i e w , F e b r u a r y 21, 1988) . T h i s p e r s p e c t i v e was e c h o e d b y a l l o f t h e s u b j e c t s . " T h e f i r s t t i m e t h e y f e e d t h e b a b y b y b o t t l e I w i l l b e a v a i l a b l e t o a n s w e r t h e i r q u e s t i o n s o r t e a c h t h e m how t o d o t h i s , b u t m o s t p a r e n t s c a n p e r f o r m t h i s a c t i v i t y w i t h m i n i m a l i n p u t f r o m t h e n u r s i n g s t a f f " (K , i n t e r v i e w , F e b r u a r y 9, 1988) s a i d o n e o f t h e ' o u r b a b y ' g r o u p . The n u r s e , h o w e v e r , p r e p a r e s t h e b o t t l e a n d t h e amount and type of feed the baby requires explained one of the subjects (G, interview, February 21, 1988). "The parents can go to i t when they come into the unit except i f i t i s the f i r s t b o t t l e the baby has had, then I w i l l either do i t myself to show them what to do or instruct them very c a r e f u l l y as to how to do i t " (I, interview, February 12, 1988) r e i t e r a t e d one of the ' t h e i r baby' group. "Most of the time the mother i s the p r i n c i p a l one to b o t t l e feed but you don't have to be female to b o t t l e feed" (E, interview, February 12, 1988) said another nurse from the ' t h e i r baby' group. 4.3.3 Breast Feeding When questioned about breast feeding there was a demonstrated difference i n perspective between the two groups of nursing s t a f f . Personal preferences flavored the perspective of the 'our baby' group of nurses i n t h i s parental a c t i v i t y . "I believe that preterm babies need breast feeding and teach mothers to do t h i s " (K, interview, February 9, 1988) said one nurse of t h i s group and she became quite animated during t h i s discussion. She could not explain why she held such strong views except to say she had breast fed her own children. This nurse stressed that she encouraged a l l mothers to breast feed. Another nurse i n t h i s group f e l t she did not have the knowledge or experience of how to a s s i s t mothers t o b r e a s t f e e d and she r e l i e d upon her peers when the mothers of 'my babies' requested a s s i s t a n c e t o b r e a s t feed (H, i n t e r v i e w , February 8, 1988) . Another nurse i n the 'our baby' group s t a t e d she had d i f f i c u l t y d e a l i n g with some mothers who i n s i s t e d t h a t they want t o b r e a s t feed when the baby was not ready t o do t h i s . "I don't argue with then I l e t them f i n d out f o r themselves" (A, i n t e r v i e w , February 18, 1988). Another nurse i n the 'our baby' group emphasized the neg a t i v e aspects of b r e a s t f e e d i n g by e x p l a i n i n g how she t e s t weighed the baby f o l l o w i n g the fe e d and t e l l i n g the mother how she had to supplement the baby with the b o t t l e f e e d i n g (D, i n t e r v i e w , February 7, 1988). T h i s p o s i t i o n was i n d i r e c t o p p o s i t i o n t o the nurse who encouraged a l l mothers t o b r e a s t feed. I t would be i n t e r e s t i n g t o compare a mothers's r e a c t i o n t o these two d i a m e t r i c a l l y o p p o s i t e p o s i t i o n s h e l d by the n u r s i n g s t a f f about b r e a s t f e e d i n g . The nurses i n the ' t h e i r baby' group tended t o base t h e i r approach t o b r e a s t f e e d i n g i n a f a m i l y centered way. When they had a s c e r t a i n e d the mothers' knowledge of the s u b j e c t these nurses then i n d i v i d u a l i z e d t h e i r t e a c h i n g approach f o r each mother. "When the baby i s ready t o b r e a s t feed o f t e n the m o t h e r s ' m i l k s u p p l y i s i n a d e q u a t e " (B , i n t e r v i e w , F e b r u a r y 6, 1988). " P a r e n t s d o n ' t r e a l i z e t h a t t h e b r e a s t f e e d i n g i s m o r e d i f f i c u l t t h a n b o t t l e f e e d i n g a n d i f t h e r e i s a s e t b a c k i n t h e b a b y ' s c o n d i t i o n a n d i t b e c o m e s i m p o s s i b l e t o b r e a s t f e e d t h e b a b y , o n c e a g a i n t h e p a r e n t s a r e i n c r i s i s " ( C , i n t e r v i e w , F e b r u a r y 4, 1988). " T h e b a b y d e c i d e s w h e n t o e a t " (E, i n t e r v i e w , F e b r u a r y 12, 1988). T h i s n u r s e t r i e d t o a l l o w some f l e x i b i l i t y w i t h i n a r i g i d f e e d i n g s c h e d u l e t o a c c o m m o d a t e b o t h t h e b a b y a n d t h e m o t h e r . She c o n t i n u e d t o s a y t h a t a l t h o u g h p h y s i c i a n s d e c i d e u p o n t h e f e e d i n g s c h e d u l e s h e t r i e s t o a i d t h e m o t h e r b y a l l o w i n g h e r o n e h o u r ' s f l e x i b i l i t y b e f o r e o r a f t e r t h e r e g u l a r f e e d i n g t i m e b e f o r e t h i s s u b j e c t w o u l d g i v e t h e b a b y a b o t t l e . N u r s e s i n t h e ' o u r b a b y ' g r o u p h a d some s i m i l a r p e r s p e c t i v e s o f b r e a s t f e e d i n g . " T h e m o t h e r l o o k s f o r w a r d t o b r e a s t f e e d i n g a n d g e t s i m p a t i e n t t o d o t h i s i n s t e a d o f e x p r e s s i n g h e r b r e a s t s a n d f e e d i n g t h e b a b y h e r b r e a s t m i l k b y b o t t l e " ( I , i n t e r v i e w , F e b r u a r y 12, 1988) . " I p h o n e t h e m o t h e r w h e n t h e b a b y w a k e s s o s h e c a n come a n d f e e d " (G , i n t e r v i e w , F e b r u a r y 21, 1988) s a i d o n e n u r s e o f t h e ' o u r b a b y ' g r o u p . A n o t h e r n u r s e o f t h e same g r o u p s a i d t h a t t h e b a b y s e t s t h e f e e d i n g s c h e d u l e b u t t h e r e was n o t m u c h f l e x i b i l i t y 47 a c c o m m o d a t i n g m o t h e r s ' v i s i t s ( L , i n t e r v i e w , F e b r u a r y 7 , 1 9 8 8 ) . The b r e a s t - f e e d i n g m o t h e r o f a p r e t e r m i n f a n t w o u l d p r o b a b l y f i n d t h a t m o s t n u r s e s i n t h i s s t u d y c o u l d a s s i s t t h e m i n b r e a s t f e e d i n g when t h e y h a d s u c c e s s f u l l y i n i t i a t e d t h i s t y p e o f f e e d i n g . H o w e v e r , m o t h e r s who r e q u i r e l o t s o f s u p p o r t a n d / o r h a v e d i f f i c u l t y e s t a b l i s h i n g f e e d i n g w o u l d f i n d t h e n u r s e s i n t h e ' t h e i r b a b y ' g r o u p m u c h m o r e e m p h a t i c t o s p e c i f i c p r o b l e m s a n d w o u l d b e e n c o u r a g e d t o p e r s e v e r e b r e a s t f e e d i n g i n s p i t e o f s e t b a c k s d u e t o a c h a n g e i n t h e b a b y ' s c o n d i t i o n . T h e s e n u r s e s i d e n t i f y a m o t h e r a n d / o r b a b y ' s s p e c i f i c n e e d s a n d u s e a n e s t a b l i s h e d k n o w l e d g e b a s e t o s o l v e p r o b l e m s . The ' o u r b a b y ' n u r s e s a r e l e s s i n c l i n e d t o r e l y u p o n k n o w l e d g e a n d s o l v e p r o b l e m s b a s e d o n t h e i r own o p i n i o n s . 4 . 3 . 4 G a v a g e F e e d i n g N e o n a t e s who n e e d t o b e g a v a g e f e d a r e u s u a l l y m o r e a c u t e l y s i c k t h a n t h o s e b a b i e s who a r e b e i n g b r e a s t a n d b o t t l e f e d . P r e t e r m i n f a n t s ' s w a l l o w r e f l e x may b e a b s e n t o r t h e y d o n o t h a v e t h e s t r e n g t h t o s w a l l o w . A t u b e i s i n t r o d u c e d t o t h e s t o m a c h t h r o u g h t h e n o s e o r m o u t h a n d t h e f e e d i s i n t r o d u c e d v i a a s y r i n g e a t t a c h e d t o t h e f e e d i n g t u b e u s i n g g r a v i t a t i o n a l f o r c e . The c o n s e n s u s o f b o t h g r o u p s o f n u r s e s was t h a t p a r e n t s o f n e w b o r n s who r e q u i r e g a v a g e f e e d i n g c o u l d 48 p a r t i c i p a t e i n t h i s a c t i v i t y b u t o n l y t o a m i n i m a l e x t e n t . P a r e n t s may h o l d t h e s y r i n g e b u t t h e n u r s e c o m p l e t e d t h e p r o c e d u r e was t h e c o n s e n s u s o f a l l t h e s u b j e c t s . P a r e n t s o f b a b i e s who a r e c h r o n i c a l l y i l l a n d r e q u i r e g a v a g e f e e d i n g a t home a r e t a u g h t t h e p r o c e d u r e a n d f e e d t h e i r b a b y b y t h i s m e t h o d w h i l e t h e y a r e i n t h e u n i t . A l l o f t h e n u r s e s i n t h e ' t h e i r b a b y ' g r o u p h a d t a u g h t p a r e n t s t h i s p r o c e d u r e b u t v e r y i n f r e q u e n t l y . F i v e o f t h e s u b j e c t s i n t h e o t h e r g r o u p h a d h a d a n o p p o r t u n i t y t o t e a c h p a r e n t s t h i s p r o c e d u r e , b u t t h e y a l l a g r e e d t h a t t h i s h a p p e n e d v e r y r a r e l y . T h e r e was l i t t l e d i f f e r e n c e i n t h e n u r s e s ' p e r s p e c t i v e o f p a r e n t a l p a r t i c i p a t i o n i n g a v a g e f e e d i n g . 4.3.5 I n t r a v e n o u s I n f u s i o n s P a r e n t s h a v e m i n i m a l p a r t i c i p a t i o n i n i n t r a v e n o u s f e e d i n g o f n e w b o r n s . M o s t o f t h e n u r s e s a g r e e d t h a t p a r e n t s d i d n o t w i s h t o b e i n v o l v e d i n t h i s t y p e o f f e e d i n g a n d m o s t w o u l d l e a v e t h e u n i t i f a n i n t r a v e n o u s i n f u s i o n h a d t o b e i n i t i a t e d . " S o m e t i m e s , f a t h e r s s t a y a n d w a t c h t h i s p r o c e d u r e , b u t I p r e f e r t h a t t h e p a r e n t s l e a v e w h i l e I am s t a r t i n g a n I . V . " ( F , i n t e r v i e w , F e b r u a r y 6, 1988) s a i d o n e n u r s e o f t h e ' o u r b a b y ' g r o u p . A n u r s e f r o m t h e o t h e r g r o u p o f s u b j e c t s s a i d " I s a v e t h e h a i r when I s h a v e t h e h e a d a n d g i v e i t t o t h e p a r e n t s ( J , i n t e r v i e w , February 14, 1988). "The parents choose t o leave because the baby c r i e s and they can comfort the baby when they r e t u r n " (E, i n t e r v i e w , February 12, 1988) s a i d a nurse from the ' t h e i r baby' group. "Parents can p a r t i c i p a t e i n t h i s a c t i v i t y by o b s e r v i n g the hand f o r p u f f i n e s s or checking the drops" (J, i n t e r v i e w , February 14, 1988) s t a t e d a nurse from the same group. When I i n q u i r e d i f anyone c o u l d a n t i c i p a t e a time parents may be i n v o l v e d i n t h i s aspect of f e e d i n g a l l the s u b j e c t s agreed t h a t they d i d not f o r e s e e t h i s happening. There i s a d i f f e r e n c e i n p e r s p e c t i v e about intravenous f e e d i n g between the two groups of nurses but i t i s one of emphasis. The nurses from the ' t h e i r baby' group t r y and f i n d something p o s i t i v e t o say about the baby and encourage parents t o soothe the i n f a n t f o l l o w i n g the procedure or g i v e them a g i f t of h a i r . The other group of nurses do not have t o i n v o l v e parents i n t h i s procedure and, t h e r e f o r e , s t i l l m a intain c o n t r o l of 'our baby'. 4.3.6 Medic a t i o n s T h i s aspect of p a r e n t a l p a r t i c i p a t i o n i s i n c l u d e d i n t h i s s e c t i o n as v i t a m i n supplements are gi v e n on a d a i l y b a s i s while f e e d i n g . There was a d i f f e r e n c e of p e r s p e c t i v e about the extent of p a r e n t a l involvement i n t h i s p a r e n t a l a c t i v i t y . 50 The 'our baby' group was l e s s i n c l i n e d t o i n c l u d e parents i n t h i s a c t i v i t y . "No, the parents don't u s u a l l y g i v e medications. I teach them about the drugs the baby r e c e i v e s i n the u n i t and d i s c u s s a d m i n i s t r a t i o n of vi t a m i n s and where to purchase them" (D, i n t e r v i e w , February 7, 1988). " I t depends on the medication and the parent. In some cases the parent i n s i s t s upon doing i t as i n the case of Mrs. P. Only i f the baby i s c h r o n i c and going home on medications do I teach parents how to do t h i s " (K, i n t e r v i e w , February 9, 1988) . "Sometimes, when I am s t a n d i n g t h e r e beside the parent and have mixed a medication i n the baby's b o t t l e , I allow the parent t o adm i n i s t e r i t " (L. i n t e r v i e w , February 7, 1988) . "The parents can gi v e v i t a m i n s i n the soother" (F, i n t e r v i e w , February 6, 1988) r e p l i e d a nurse from t h i s group. "The parents can g i v e v i t a m i n s but no other medications u n l e s s t h e r e i s a s p e c i a l reason" (H, i n t e r v i e w , February 8, 1988) . "Most parents do ad m i n i s t e r medications i n d i r e c t l y when they g i v e a b o t t l e t h a t has had v i t a m i n s added t o i t " (G, in t e r v i e w , February 21, 1988) s t a t e d another member of the 'our baby' group. "Parents do ad m i n i s t e r medications on occasions but only o r a l medications not i n t r a m u s c u l a r " (C, i n t e r v i e w , February 4, 51 1988) answered one nurse from the ' t h e i r baby' group. "The nurse pours the medication and the parent can s q u i r t i t i n the mouth" (J, i n t e r v i e w , February 14, 1988) e x p l a i n e d another member of the same group. "The nurse u s u a l l y a d m i n i s t e r s drugs but parents of c h r o n i c babies do l e a r n how t o do t h i s and perform t h i s a c t i v i t y i n the u n i t " (B, i n t e r v i e w , February 6, 1988) . "I get the parents t o check with me and then they go ahead and g i v e the medication once they have been taught how to do t h i s " (I, i n t e r v i e w , February 12, 1988) was how t h i s nurse d e s c r i b e d the p r o c e s s . Another nurse from t h i s group s a i d t h a t because she was r e s p o n s i b l e f o r a d m i n i s t r a t i o n of medications she always poured the drugs which had to be mixed with the i n f a n t ' s feed and prepared t h i s f o r parents t o adm i n i s t e r (B, i n t e r v i e w , February 6, 1988) . Parents who have a nurse from the ' t h e i r baby' group are more l i k e l y t o l e a r n about and ad m i n i s t e r medications t o the neonate than those who have a nurse from the other group of s u b j e c t s . 4.3.7 Summary of Nurses' P e r s p e c t i v e s of Infant Feeding Table I, on the f o l l o w i n g page, i s a synopsis of the d i f f e r e n c e i n nurses' p e r s p e c t i v e s of p a r e n t a l p a r t i c i p a t i o n i n i n f a n t f e e d i n g . Comments t h a t the s u b j e c t s made i n r e f e r e n c e t o v a r i o u s f e e d i n g a c t i v i t i e s are l i s t e d and d i v i d e d 52 i n t o ' t h e i r baby' and 'our baby' columns. Gavage and intravenous f e e d i n g are not i n c l u d e d i n t h i s t a b l e because t h e r e was l i t t l e d i f f e r e n c e i n the p e r s p e c t i v e s of the two groups. PERSPECTIVES OF PARENTAL PARTICIPATION IN INFANT FEEDING TABLE I THEIR BABY OUR BABY BOTTLE FEEDING Cannot teach the baby so teach the parents F l e x i b l e schedule Recognize feeding cues Parents have to f i t into the schedule Parents feeding baby increases workload BREAST FEEDING Ind i v i d u a l i z e d approach Demand feeding Help to overcome setbacks A l l preterms should be breast fed No experience of breast feeding Let parents f i n d out for themselves MEDICA-TIONS Parents give o r a l medications Teach parents about medications being administered Parents don't usually give medications I f a parent has a chronic baby then teach them about medications 53 The major d i f f e r e n c e i n nurses' p e r s p e c t i v e s appears to r e p r e s e n t a l o s s of c o n t r o l over the care of the baby. The ' t h e i r baby' group of s u b j e c t s a p p r e c i a t e s the parents problems and endeavors t o i n v o l v e them i n i n f a n t f e e d i n g . The 'our baby' s u b j e c t s have a standard c l i n i c a l approach and expect parents to accommodate the nurse's work schedule. Nurses' p e r s p e c t i v e s of other a c t i v i t i e s when parents are p a r t i c i p a t i n g i n care w i l l be d i s c u s s e d i n the f o l l o w i n g s e c t i o n s of the chapter. 4.4 P e r s p e c t i v e s of P a r e n t a l P a r t i c i p a t i o n i n Infant Bathing. A l l of the nurses i n t h i s study d e s c r i b e d t h e i r p e r s p e c t i v e of p a r e n t a l p a r t i c i p a t i o n i n i n f a n t b a t h i n g i n a s i m i l a r way. "The nurse teaches the parent to bathe t h e i r baby and e v a l u a t e s t h e i r performance of t h i s procedure" (K, i n t e r v i e w , February 7, 1988). T h i s s u b j e c t from the 'our baby' group went on t o say t h a t "when I am s a t i s f i e d with a parent's performance of a baby bath and f e e l t h a t he/she i s p r o f i c i e n t , the parent can choose to bathe the baby at whatever time he/she v i s i t s i n a twenty-four hour p e r i o d " . The comments from the ' t h e i r baby' nurses i n c l u d e d "the parent decides the b a t h i n g schedule" (C, i n t e r v i e w , February 4, 1988) and they can do i t at any time". (F, i n t e r v i e w , February 6, 1988). 54 " T h e o n l y r e s t r i c t i o n u p o n t h i s a c t i v i t y i s t h a t t h e p a r e n t s ' a r e r e q u e s t e d n o t t o b a t h e t h e i r b a b y d i r e c t l y a f t e r f e e d i n g " e x p l a i n e d t h e same s u b j e c t . T h i s r e s t r i c t i o n i s w r i t t e n i n a n u r s i n g p r o c e d u r e a n d i s f o l l o w e d b y t h e n u r s i n g s t a f f i n t h e s p e c i a l c a r e n u r s e r y b e c a u s e t h e b a b y i s d i s t u r b e d d u r i n g b a t h i n g a n d may r e g u r g i t a t e i f t h e y a r e f e d d i r e c t l y f o l l o w i n g a b a t h . P a r e n t s w o u l d f i n d l i t t l e c o n f l i c t i n n u r s e s ' p e r s p e c t i v e o f t h i s a c t i v i t y . 4 . 5 P e r s p e c t i v e s o f P a r e n t a l P a r t i c i p a t i o n i n I n f a n t D r e s s i n g . A l l o f t h e n u r s e s i n t h e s t u d y c o n c u r r e d t h a t p a r e n t s c o u l d c h o o s e t o d r e s s t h e i r b a b y i n w h a t e v e r m a n n e r t h e y c h o s e a s l o n g a s t h e b a b y was c o m f o r t a b l e a n d w a r m . H o w e v e r , t h e r e w e r e d i f f e r e n c e s i n t h e way t h e t w o g r o u p s d e s c r i b e d t h i s s u b j e c t . " I t m a k e s t h e p a r e n t s f e e l b e t t e r a n d i t i s t h e i r b a b y s o t h e y c a n d r e s s t h e b a b y a n y w a y t h e y l i k e " ( C , i n t e r v i e w , F e b r u a r y 4 , 1 9 8 8 ) ; " p a r e n t s i d e n t i f y w i t h t h e b a b y when h e / s h e i s d r e s s e d i n t h e i r own c l o t h i n g " ( E , i n t e r v i e w , F e b r u a r y 1 2 , 1988) w e r e r e p l i e s f r o m t w o m e m b e r s o f t h e ' t h e i r b a b y ' g r o u p . T h e members o f t h e ' o u r b a b y ' g r o u p d i d n o t r e f e r t o p a r e n t a l r e a c t i o n w h e n t h e b a b y w a s d r e s s e d i n t h e i r own c l o t h i n g . T h i s d i s t i n g u i s h e s t h e m f r o m o t h e r i n f a n t s i n 55 the u n i t . Three of them s t a t e d t h a t as long as the baby-c l o t h e s were not u n s u i t a b l e and the nurse was able t o see the baby, the parents c o u l d dress the baby i n what ever manner they chose. 4.6 P e r s p e c t i v e s of P a r e n t a l P a r t i c i p a t i o n i n Phototherapy. The s u b j e c t s a l s o concurred i n t h e i r p e r s p e c t i v e about p a r e n t a l p a r t i c i p a t i o n i n care r e g a r d i n g phototherapy. The parent c o u l d continue t o f e e d and bathe the baby and t o perform the procedure themselves when the nurse was comfortable with t h e i r performance. R e s u l t s of the b i l i r u b i n t e s t were d i s c u s s e d i n a s i m i l a r way by a l l of the s u b j e c t s . The nurses d i s c u s s e d t h i s i n f o r m a t i o n with the parents i n terminology they understood. "Numbers (the r e s u l t s of the b i l i r u b i n t e s t ) mean very l i t t l e but i f they want s p e c i f i c numbers I w i l l t e l l them" (J, i n t e r v i e w , February 14, 1988) s a i d one nurse from the ' t h e i r baby' group. "I d i s c u s s the r e s u l t s with the parents as they ask me anyway" (A, i n t e r v i e w , February 18, 1988) s a i d one of the s u b j e c t s from the other group. The nurses d e a l with t h i s c o m p l i c a t i o n of i n f a n t s f r e q u e n t l y and are f a m i l i a r with d i s c u s s i n g t h i s common occurrence with p a r e n t s . There was no i n d i c a t i o n d u r i n g the i n t e r v i e w s of a d i f f e r e n c e of p e r s p e c t i v e between the two 5 6 groups of parental p a r t i c i p a t i o n i n t h i s a c t i v i t y . 4.7 Perspectives of Parent-Infant Interaction. There was a divergence of nursing perspectives of parent-infant i n t e r a c t i o n between the two groups of nurses. The 'our baby' group of nurses l i s t e d a c t i v i t i e s that parents could do to bond with t h e i r baby, but did not consider any psychosocial needs. "Parents can watch, touch and hold the baby" (K, interview, February 9, 1988) . One nurse stated that "during the i n i t i a l v i s i t she encouraged the parents to touch the baby" (L, interview, February 7, 1988) and another "encouraged the parents to t a l k through the portholes" (H, interview, February 8, 1988) . None of t h i s group of nurses discussed parental reaction to the b i r t h of a preterm infant and how t h i s may in t e r f e r e with t h e i r communication with the baby or the nursing s t a f f . The ' t h e i r baby' group of nurses often referred to parent-infant i n t e r a c t i o n i n regard to various parental a c t i v i t i e s i n the special care nursery. In the opening statement when they described t h e i r perspective of parent p a r t i c i p a t i o n each nurse in t h i s group mentioned parent-infant in t e r a c t i o n . " I t depends on the baby's condition as some parents are t e r r i f i e d to communicate with t h e i r baby" (C, interview, February 4, 1988) . "Fathers often have a more d i f f i c u l t time in t e r a c t i n g with the baby as they have to preserve t h e i r macho image" (G, interview, February 14, 1988) . " I t a l k to the parents about the baby and t e l l them he i s a person even i f he does not survive, he i s a baby and he i s t h e i r s " (E, interview, February 12, 1988) . "I t e l l them to ta l k to the baby, say h i sweetheart, and then get them to touch" (B, interview, February 6, 1988) . However, no one i n the group was very f a m i l i a r with an infant stimulation program. One nurse i n the 'our baby' group did have knowledge and experience teaching parents to stimulate t h e i r baby. When infants have been chronically i l l i t i s believed that infant stimulation programs benefit t h e i r growth and development. This nurse had completed a project i n t h i s area during her university nursing program (G, interview, February 21, 1988). Other s t a f f r e l i e d upon the occupational therapist to develop and i n s t i t u t e an infant stimulation program. 4.8 Perspectives of Parental Counselling. Counselling was another area where there was a difference i n nursing perspectives of parental p a r t i c i p a t i o n i n care. A l l 58 of the nurses mentioned teaching and counselling parents on a d a i l y basis. The subjects t o l d me they were i n contact with, at least, one and up to ten sets of parents i n a normal working day. We meet more parents i n the day time.... not as many at night and a l o t of nurses l i k e t h i s because there are not many parents around" (G, interview, February 21, 1988) explained one nurse from the 'our baby' group. A nurse from the 'their baby' group t o l d me she phoned parents who had not v i s i t e d the baby to give them information and to discover why they had not v i s i t e d (B, interview, February 6, 1988) . "In the beginning, when you f i r s t meet the parent, you are spending a l o t of time with them and as they are f e e l i n g more comfortable with the baby you're not spending so much time with them. So, i n i t i a l l y , for a newborn, or a preemie that's been transferred, or a sick baby you spend a l o t of time with the parents and that depends on how many babies you've got" (I, interview, February 12, 1988) . This answer came from one of the ' t h e i r baby' group. Two more members of t h i s group said that the time they spend with the parent was dependent upon the acuity of care (C, interview, February 4; J , interview February 14, 1988). "Each parent i s d i f f e r e n t and some require more time than others, i t ' s a very i n d i v i d u a l thing" (J, interview, February 14, 1988). "It's d i f f i c u l t to say how much time I spend with parents, i t depends on the baby and the p a r e n t s " (E, i n t e r v i e w , February 12, 1988). The members of the ' t h e i r baby' group p e r s p e c t i v e of p a r e n t a l c o u n s e l l i n g i n c l u d e d c o n s i d e r a t i o n of the i n d i v i d u a l needs of parents i n r e l a t i o n t o t h e i r s p e c i f i c needs. The n u r s i n g p e r s p e c t i v e s of p a r e n t a l c o u n s e l l i n g mentioned by members of the 'our baby' group of s u b j e c t s d i f f e r e d from t h e i r p e ers. The d i f f e r e n c e again was one of emphasis. "The parents are t h e r e and you do your own t h i n g " (L, i n t e r v i e w , February 7, 1988) . "Some (parents) are more d i f f i c u l t than o t h e r s " (H, i n t e r v i e w , February 8, 1988). "One parent, who i s c u r r e n t l y v i s i t i n g a preterm i n f a n t , who i s c h r o n i c a l l y i l l and has severe b r a i n damage, s t i l l t h i n k s t h a t m i r a c l e s w i l l happen and i s very demanding and causes l o t s of problems f o r the s t a f f " (A, i n t e r v i e w , February 18, 1988) . T h i s nurse went on to say t h a t the s t a f f needed l o t s of s k i l l s t o d e a l with her. Another nurse mentioned the same mother and s a i d she "does not l i k e many of the s t a f f and r e f u s e s t o have some of the nurses look a f t e r her baby" (L, i n t e r v i e w , February 7, 1988) . When I asked how they d e a l t with these problems both nurses s a i d t h a t when th e r e were p e r s o n a l i t y c o n f l i c t s with parents, other s t a f f were as s i g n e d t o look a f t e r those babies t o a v o i d f u r t h e r c o n f l i c t . "Some nurses are b e t t e r with d i f f i c u l t p arents than o t h e r s " was one e x p l a n a t i o n (K, i n t e r v i e w , February 9, 1988). Nurses i n the ' t h e i r baby' group enjoyed i n t e r a c t i n g with the parents i n the s p e c i a l care n u r s e r y . "Everyone has a d i f f e r e n t l i f e s t y l e , some parents are warm, some are c o l d . You almost have t o be a p s y c h o l o g i s t t o d e a l with f a m i l i e s " (B, i n t e r v i e w , February 6, 1988) . She went on t o say she enjoyed " a l l aspects of p a r e n t a l p a r t i c i p a t i o n , g e t t i n g p a rents i n v o l v e d and s e e i n g them doing i t i s wonderful. I don't f o r c e anyone i n t o doing anything they don't want t o do". Another nurse s a i d she used common sense t o d e a l with parents as "each one i s an i n d i v i d u a l and I f i n d i t c h a l l e n g i n g t o d e a l with parents who are d i f f i c u l t . I enjoy i t when they f i n a l l y come around" (J, i n t e r v i e w , February 14, 1988). "I enjoy t a l k i n g t o parents and b e i n g t h e r e at major h u r d l e s , f o r example, the wonder of h o l d i n g the baby f o r the f i r s t time, or coming out of oxygen" (C, i n t e r v i e w , February 4, 1988) . S i m i l a r l y , another s u b j e c t from the group s a i d "observing the parents and, e s p e c i a l l y , h e l p i n g t o counsel them when the baby i s g e t t i n g ready t o go home i s one t h i n g I enjoy" (E, in t e r v i e w , February 12, 1988) . 61 On the other hand, the same s u b j e c t s d i d say they d i d not enjoy c e r t a i n aspects of p a r e n t a l p a r t i c i p a t i o n . The major problem f o r these nurses seemed t o be p a r t i c u l a r aspects of p a r e n t a l c o u n s e l l i n g . "I l i k e some parents more than others so i t i s e a s i e r f o r me t o d e a l with those I l i k e " (C, i n t e r v i e w , February 4, 1988). " H o s t i l e parents are d i f f i c u l t t o communicate with and anything you suggest they snap at you, blame something on you or the do c t o r . These people are more d i f f i c u l t than emotional, angry or out of c o n t r o l p a r e n t s . You l i s t e n t o them once they begin t o v e r b a l i z e and then they f e e l b e t t e r " (B, i n t e r v i e w , February 6, 1988) e x p l a i n e d another s u b j e c t . In the same v e i n one nurse t o l d me t h a t once she breaks down the communication b a r r i e r s with d i f f i c u l t p a rents the r e l a t i o n s h i p t h a t develops between the nurse and the parents i s q u i t e s p e c i a l . "Some of these parents b r i n g t h e i r babies back t o v i s i t us when they have gone home" (J, in t e r v i e w , February 14, 1988) . "I f e e l h e l p l e s s when d e a l i n g with parents of a dying c h i l d as i t i s d i f f i c u l t t o say p o s i t i v e t h i n g s about the baby" (E, i n t e r v i e w , February 12, 1988). The nurses i n the ' t h e i r baby' group found ' d i f f i c u l t p a r e n t s ' a c h a l l e n g e and t r i e d t o form a r e l a t i o n s h i p t h a t was meaningful t o understand why parents react n e g a t i v e l y t o the b i r t h of a preterm baby. 62 " T e a c h i n g a n d c o u n s e l l i n g p a r e n t s i s f u n " ( A , i n t e r v i e w , F e b r u a r y 18, 1988) s t a t e d o n e n u r s e f r o m t h e ' o u r b a b y ' g r o u p , " e s p e c i a l l y when t h e b a b y i s g e t t i n g b e t t e r " . " I e n j o y t a l k i n g t o t h e p a r e n t s a n d h e l p i n g t h e m u n d e r s t a n d t h e i r b a b y " ( K , i n t e r v i e w , F e b r u a r y 9, 1988) s a i d a n o t h e r member o f t h e g r o u p . 4.9 Summary o f N u r s e s ' P e r s p e c t i v e s o f P a r e n t a l P a r t i c i p a t i o n i n D r e s s i n g , P a r e n t / I n f a n t I n t e r a c t i o n a n d C o u n s e l l i n g . T a b l e I I , o n t h e f o l l o w i n g p a g e , i s a s y n o p s i s o f n u r s i n g c o m m e n t s made i n r e l a t i o n t o i n f a n t d r e s s i n g , p a r e n t / i n f a n t i n t e r a c t i o n a n d p a r e n t a l c o u n s e l l i n g . I n f a n t b a t h i n g a n d p h o t o t h e r a p y h a v e n o t b e e n i n c l u d e d b e c a u s e t h e r e was l i t t l e d i f f e r e n c e i n t h e p e r s p e c t i v e s o f t h e t w o g r o u p s o f s u b j e c t s . T h e c o m m e n t s a r e d i v i d e d i n t o b o x e s r e p r e s e n t i n g c o m m e n t s f r o m t h e ' t h e i r b a b y ' a n d ' o u r b a b y ' g r o u p s o f n u r s e s . NURSES' PERSPECTIVES OF PARENTAL ACTIVITIES TABLE II THEIR BABY' OUR BABY INFANT DRESSING Makes the parent f e e l b etter Parent I d e n t i f i e s with t h e i r baby The c l o t h i n g must be sui t a b l e The nurse must be able to see the baby PARENT INFANT INTER-ACTION The baby i s a person Fathers' have a d i f f i c u l t time A preterm b i r t h i s a c r i s i s f o r parents No nurse i n t h i s group mentioned bonding The nurses have a l i s t of tasks parents can perform COUNSE-LLING Enjoy parents Spend time with parents Each parent i s d i f f e r e n t At night there are not too many parents Parents are there and you do your own thing 64 The m a j o r d i f f e r e n c e i n t h e n u r s e s ' p e r s p e c t i v e s i s t h a t t h e ' t h e i r b a b y ' g r o u p s e e s t h e p a r e n t s a s a n i n t e g r a l p a r t o f t h e c a r e o f t h e b a b y a n d r e c o g n i z e s e a c h o n e a s a n i n d i v i d u a l w i t h p a r t i c u l a r n e e d s . On t h e o t h e r h a n d , t h e ' o u r b a b y ' g r o u p o f s u b j e c t s t e n d s t o v i e w p a r e n t a l p a r t i c i p a t i o n a s s o m e t h i n g w i t h w h i c h t h e y h a v e t o c o p e a n d t h a t p a r e n t s i n t e r f e r e w i t h t h e n u r s e s ' c a r e o f t h e p r e t e r m i n f a n t . P a r e n t s w o u l d f i n d t h a t t h e n u r s e s i n t h e ' t h e i r b a b y ' g r o u p w o u l d l i s t e n t o t h e m a n d h e l p t h e m c o p e w i t h t h e s t r e s s o f t r y i n g t o p a r e n t a s i c k b a b y . 4 . 1 0 Summary o f R e s e a r c h Q u e s t i o n O n e . I n summary t h e r e was a d e m o n s t r a t e d d i f f e r e n c e o f n u r s e s ' p e r s p e c t i v e s c o n c e r n i n g p a r e n t a l p a r t i c i p a t i o n i n a s p e c i a l c a r e n u r s e r y b e t w e e n t h e t w o g r o u p s o f n u r s e s . I t i s u s e f u l t o n o t e t h a t t h e m a j o r d i f f e r e n c e i n t h e n u r s e s ' p e r s p e c t i v e s was i n r e l a t i o n t o p a r e n t i n g s k i l l s , s u c h a s i n f a n t f e e d i n g , a n d t h e r e was l e s s d i s t i n c t i o n when t h e p a r e n t s w e r e p a r t i c i p a t i n g i n n u r s i n g c a r e , s u c h a s i n t r a v e n o u s i n f u s i o n s . The c h o i c e o f f e e d i n g , b r e a s t o r b o t t l e , was d e c i d e d b y p a r e n t s ( t h o u g h i n f l u e n c e d b y n u r s e s ) a n d t h e y w o u l d f i n d t h a t t h e n u r s e s i n t h e ' t h e i r b a b y ' g r o u p m u c h m o r e e m p a t h e t i c t o i n d i v i d u a l n e e d s . T h e s e n u r s e s w o u l d b e f l e x i b l e b y b e n d i n g 65 t h e r u l e s o f a r i g i d f e e d i n g s c h e d u l e a n d b y b e i n g m o r e s u p p o r t i v e o f p a r e n t s . The ' o u r b a b y ' n u r s e s w o u l d b e l e s s h e l p f u l a n d w o u l d t e n d t o a c c o m m o d a t e t h e p a r e n t t o f i t t h e n u r s e ' s s c h e d u l e r a t h e r t h a n v i e w t h i s a s a f a m i l y t i m e . M e m b e r s o f t h e ' o u r b a b y ' g r o u p t e n d e d t o u s e t h e i r p e r s o n a l i d e a s r a t h e r t h a n a n e s t a b l i s h e d k n o w l e d g e b a s e w h e n s u p p o r t i n g t h e m o t h e r t o e s t a b l i s h b r e a s t f e e d i n g w h i c h w o u l d b e v e r y d i s h e a r t e n i n g when a p r e t e r m b a b y d o e s n o t r e s p o n d a p p r o p r i a t e l y . One n u r s e e n c o u r a g e d a l l m o t h e r s t o b r e a s t f e e d w h i l e a n o t h e r r e l i e d o n h e r p e e r s t o a s s i s t w i t h t h i s a c t i v i t y . The m o r e t e c h n i c a l m e t h o d s o f f e e d i n g , g a v a g e a n d i n t r a v e n o u s i n f u s i o n s , a r e a c t i v i t i e s t h a t a l l o f t h e s u b j e c t s a l l o w e d p a r e n t a l p a r t i c i p a t i o n t o a s i m i l a r e x t e n t . The ' t h e i r b a b y ' s u b j e c t s t a u g h t p a r e n t s a b o u t m e d i c a t i o n a d m i n i s t r a t i o n a n d w e r e m o r e w i l l i n g t o a l l o w p a r e n t s t o b e i n v o l v e d i n t h i s a c t i v i t y w i t h i n t e c h n i c a l b o u n d a r i e s . T h e r e was a l s o a d i f f e r e n c e i n n u r s e s ' p e r s p e c t i v e s r e g a r d i n g p a r e n t - i n f a n t i n t e r a c t i o n a n d p a r e n t c o u n s e l l i n g . The ' t h e i r b a b y ' g r o u p d i s c u s s e d p r i n c i p l e s o f p a r e n t - i n f a n t a t t a c h m e n t r e l a t e d t o f a m i l y c e n t e r e d c a r e d u r i n g t h e i n t e r v i e w s . T h e s e s u b j e c t s d e s c r i b e d how t h e y e n c o u r a g e d f a m i l y members t o s h a r e w h a t t h e e x p e r i e n c e o f a p r e t e r m b i r t h m e a n t f o r t h e m . D e a l i n g w i t h p a r e n t s who e x h i b i t a n u m b e r o f e m o t i o n a l b e h a v i o r s i s o f t e n a v e r y s t r e s s f u l t i m e f o r t h e n u r s i n g s t a f f , b u t t h e y saw t h i s a s a c h a l l e n g e a n d p a r t o f t h e j o b . On t h e o t h e r h a n d , t h e ' o u r b a b y ' n u r s e s h a d a t a s k o r i e n t e d a p p r o a c h t o f a m i l y i n t e r a c t i o n a n d v i e w e d p a r e n t c o u n s e l l i n g a s s o m e t h i n g t h a t was d i f f i c u l t a n d w i t h w h i c h t h e y w o u l d r a t h e r h a v e a n o t h e r s t a f f member d e a l . The c h a n g e i n v i s i t i n g p o l i c y g i v i n g p a r e n t s c o n t r o l o v e r v i s i t i n g a l s o e m p h a s i z e d t h e d i f f e r e n c e i n p e r s p e c t i v e s . The ' t h e i r b a b y ' g r o u p saw t h i s a s a p o s i t i v e s t e p f o r p a r e n t s b u t t h e o t h e r g r o u p s t r e s s e d t h a t t h i s was a n e g a t i v e e x p e r i e n c e f o r t h e n u r s i n g s t a f f a s i t i n t e r f a c e d w i t h w o r k l o a d . T h e r e was l e s s d i s t i n c t i o n b e t w e e n n u r s e s ' p e r s p e c t i v e s i n o t h e r a s p e c t s o f p a r e n t a l p a r t i c i p a t i o n i n c a r e . The c o n s e n s u s o f a l l o f t h e s u b j e c t s was t h a t p a r e n t s c o u l d c h o o s e t o b a t h e t h e i r b a b y a t a n y t i m e o f t h e d a y o r n i g h t . I f t h e b a b y r e q u i r e d p h o t o t h e r a p y t h e n u r s e s f r o m b o t h g r o u p s i n v o l v e d t h e p a r e n t s i n c a r e i n a s i m i l a r w a y . P a r e n t s c o u l d d r e s s t h e b a b y i n c l o t h e s t h a t t h e y b r o u g h t t o t h e u n i t a n d w o u l d f i n d t h a t n o n e o f t h e n u r s e s w o u l d o b j e c t e x c e p t o n e o r 67 t w o o f t h e ' o u r b a b y ' g r o u p who may c o n s i d e r t h e m t o b e a h i n d r a n c e t o c a r e . The ' t h e i r b a b y ' g r o u p e n c o u r a g e d p a r e n t s t o d r e s s t h e b a b y i n c l o t h i n g t h e y b r o u g h t t o t h e u n i t a s t h i s was o n e way t h e y c o u l d i d e n t i f y t h e b a b y a s t h e i r own c h i l d , t h u s b r i n g i n g t h e m c l o s e r t o g e t h e r . R E S E A R C H Q U E S T I O N TWO The n e x t s e c t i o n o f t h i s c h a p t e r w i l l d i s c u s s how n u r s i n g p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n c a r e i s r e l a t e d t o t h e s e t t i n g a n d t h e p r o f e s s i o n a l a n d p e r s o n a l c h a r a c t e r i s t i c s o f t h e n u r s e s i n t h i s s t u d y . P r e v i o u s r e s e a r c h u s i n g t h e s t r u c t u r a l v a r i a b l e s o f a g e , e d u c a t i o n a l s t a t u s , l e v e l o f n u r s i n g e d u c a t i o n a n d p a r e n t a l s t a t u s h a s i n d i c a t e d t h a t t h e r e a r e d i f f e r e n c e s i n n u r s e s ' a t t i t u d e s t o w a r d s p a r e n t a l p a r t i c i p a t i o n i n c a r e . 4.11 A c c o u n t a b i l i t y . The n u r s e i s a c c o u n t a b l e f o r c a r e a n d s h e c o u l d b e h e l d r e s p o n s i b l e f o r s o m e t h i n g a p a r e n t d o e s , o r f a i l s t o d o , w h i l e p a r t i c i p a t i n g i n t h e c a r e o f t h e b a b y . D i f f e r e n c e s i n p e r s p e c t i v e b e t w e e n t h e t w o g r o u p s a b o u t a c c o u n t a b i l i t y r e f l e c t e d d i f f e r e n t i d e a s a b o u t t h e i s s u e o f c o n t r o l . The ' t h e i r b a b y ' g r o u p a c t i v e l y p a r t i c i p a t e d w i t h p a r e n t s i n c a r e , 68 e s t a b l i s h i n g communication channels t o i d e n t i f y the parents' needs as demonstrated i n p a r t one of t h i s study. They f e l t c omfortable d e a l i n g with parents and a n t i c i p a t e d p o t e n t i a l problems t o reduce the p o s s i b i l i t y of unsafe p r a c t i c e s i n ca r e . The 'our baby' group was not w i l l i n g t o al l o w parents t o p a r t i c i p a t e i f they a n t i c i p a t e d problems and maintained c o n t r o l , thereby r e d u c i n g the p o s s i b i l i t y of b e i n g h e l d accountable f o r i n c o r r e c t care t h a t they had not admini s t e r e d . The nurses i n the ' t h e i r baby' group d e s c r i b e d t h e i r e xperiences i n the f o l l o w i n g ways. "I am concerned about the s a f e t y of the baby when the parents are nervous and don't perform i d e a l l y , but I t r y not t o say r i g h t or wrong, I t r y t o show them and b i t e my tongue. I t ' s no b i g d e a l whether they do i t wrong. For example, i n bathing, the only bad t h i n g i s i f they drown the baby" (C, i n t e r v i e w , February 4, 1988) . Another member of the group s a i d t h a t her only concern r e g a r d i n g a c c o u n t a b i l i t y o c c u r r e d i f the parent was a "drug a d d i c t or had the D.T.'s" (E, i n t e r v i e w , February 12, 1988). She c o n t i n u e d t o e x p l a i n how she coped with t h i s type of parent by s a y i n g t h a t she d i d not venture f a r from the baby when they were v i s i t i n g . A t h i r d nurse from the same group s a i d t h a t new parents caused her some concern, but she 69 p r o v i d e d e x t r a t e a c h i n g a n d c o u n s e l l i n g t o a s s i s t t h e m i n c o p i n g w i t h p a r e n t i n g a c t i v i t i e s ( J , i n t e r v i e w , F e b r u a r y 14, 1988) . " N o I h a v e n o c o n c e r n s i f t h e p a r e n t s h a v e b e e n s u p e r v i s e d t o p r o v i d e c a r e , I j u s t e n s u r e t h e y d o e v e r y t h i n g r i g h t " (B , i n t e r v i e w , F e b r u a r y 8, 1988) . " I n e v e r t h o u g h t a b o u t i t " ( I , i n t e r v i e w , F e b r u a r y 12, 1988) s t a t e d t h e f i f t h n u r s e f r o m ' t h e i r b a b y ' g r o u p . M o s t o f t h e n u r s e s i n t h e ' o u r b a b y ' g r o u p d i d n o t f i n d a n y p r o b l e m s i n . t h e a r e a o f a c c o u n t a b i l i t y w h e n p a r e n t s w e r e i n v o l v e d i n c a r e . The n u r s e s e n s u r e d t h a t t h e p a r e n t s h a d b e e n t a u g h t t o d o a n a c t i v i t y b e f o r e t h e y b e g a n t o p a r t i c i p a t e i n c a r e . " I d o n ' t l e t t h e m do s o m e t h i n g u n l e s s t h e y a r e c o m f o r t a b l e a n d t h e y d o n ' t d o a n y t h i n g u n l e s s t h e y a r e c o m f o r t a b l e w i t h t h e b a b y " (G , i n t e r v i e w , F e b r u a r y 21, 1988) . " M o s t p a r e n t s a r e v e r y c a r e f u l w i t h t h e i r b a b y " ( L , i n t e r v i e w , F e b r u a r y 7, 1988); K , i n t e r v i e w , F e b r u a r y 9, 1988). " T h e n u r s e i s r e s p o n s i b l e a n d i t d e p e n d s o n t h e c o n d i t i o n o f t h e c h i l d a n d t h e i n d i v i d u a l p a r e n t . I f t h e p a r e n t s a r e h a p p y w i t h t h e c a r e t h e b a b y r e c e i v e s i n t h e u n i t I h a v e n o w o r r i e s " (D, i n t e r v i e w , F e b r u a r y 7, 1988) . T h i s s u b j e c t d i d n o t w i s h t o p u r s u e t h i s t o p i c a n y f u r t h e r a n d a s k e d t h a t we c o n t i n u e t o t h e n e x t q u e s t i o n i n t h e i n t e r v i e w . On t h e w h o l e , t h e members of both groups expressed few concerns about a c c o u n t a b i l i t y when parents p a r t i c i p a t e d i n care, but f o r d i f f e r e n t reasons. The ' t h e i r baby' group a c t i v e l y p a r t i c i p a t e d with parents and d i s c u s s e d concerns t o ensure t h a t they gave a p p r o p r i a t e c a r e . The 'our baby' group were l e s s l i k e l y t o allow parents t o p a r t i c i p a t e without b e i n g i n c o n t r o l of the s i t u a t i o n . 4.12 Workload. The next q u e s t i o n i n the i n t e r v i e w e x p l o r e d the n u r s i n g workload i n r e l a t i o n t o p a r e n t a l p a r t i c i p a t i o n i n care i n the s p e c i a l care nursery. The two groups' p e r s p e c t i v e of workload and p a r e n t a l p a r t i c i p a t i o n d i f f e r e d . The 'our baby' group of nurses tended t o view p a r e n t a l p a r t i c i p a t i o n i n care as something t h a t i n c r e a s e d t h e i r workload. " I t i n c r e a s e s the workload a l o t i f you have a l l your parents i n " (G, i n t e r v i e w , February 21, 1988) s a i d one nurse of t h i s group. "When you're busy you can't spend time with p a r e n t s " (F, i n t e r v i e w , February 6, 1988). "They have t o wait u n t i l you're ready t o de a l with them, but sometimes the u n i t i s too busy and you can't spend very long with them" (K, i n t e r v i e w , February 9, 1988) . When I probed i n t o the p o s s i b i l i t y t h a t p a r e n t a l p a r t i c i p a t i o n i n care may r e l i e v e the workload, some of the nurses i n t h i s group agreed t h a t t h i s was so. " I f you have four babies and two parents feed the baby that does help" (F, interview, February 6, 1988); "but you s t i l l have to keep your eye on them" (A, interview, February 18, 1988) . One nurse from t h i s group said that when she was busy she would arrange to share some of her workload with a colleague so that she could spend more time with parents who required her assistance (D, interview, February 7, 1988), and she continued by saying that t h i s was not always possible. The subjects i n t h i s group viewed parental p a r t i c i p a t i o n as a loss of control i n the care of the preterm baby rather than a decrease i n workload. The ' t h e i r baby' group seemed to view parental p a r t i c i p a t i o n as a p o s i t i v e contribution to the care of the infant when nurses had a heavy workload. "Parents help, es p e c i a l l y when the unit i s busy" (B, interview, February 6, 1988) . " If a l l the kids are at the same stage i t ' s great, but when you have f i v e babies a l l at d i f f e r e n t stages i t i s d i f f i c u l t to s p l i t yourself into f i v e " (C, interview, February 4, 1988). "You spread yourself out to meet the needs of ind i v i d u a l parents and once they know what they are doing they help a great deal" (J, interview, February 14, 1988) . "You set your p r i o r i t i e s and i t ' s hard sometimes but i f you have taught the parents to care for t h e i r baby then you can spend more time with other 72 parents who need teaching" (I, interview, February 12, 1988) . This group of nurses viewed parental p a r t i c i p a t i o n i n care as a way to a s s i s t with workload allowing them to spend more time with parents who require teaching or counselling, e s p e c i a l l y when the unit i s busy. On the other hand, the 'our baby' nurses did not volunteer that parents could help when they were busy; only when the question was probed did they admit that parental p a r t i c i p a t i o n i n care could reduce workload. 4.13 Resources. When questioned about whether the nurse had any resources available to aid when problems arose with parental p a r t i c i p a t i o n i n care most of the subjects stated that there were appropriate resources within the agency and, especially, the special care nursery. Many of the subjects said that the head nurse, assistant head nurse or team leader were available resources for the s t a f f . Others said that they requested assistance from t h e i r peers. "Some nurses l i k e to work more than others" (F, interview, February 6, 1988) and t h i s nurse from the 'our baby' group went on to say that resources were dependent upon the time of day and the s t a f f who were on duty during the evening s h i f t . "Few parents v i s i t during the night s h i f t so the nurses did not require resources for parental 73 p a r t i c i p a t i o n at t h a t p a r t of the day" (G, i n t e r v i e w , February 21, 1988) was the c o n c l u s i o n of one su b j e c t from the 'our baby' group. The nurses from the ' t h e i r baby' group agreed t h a t t h e r e were enough and a p p r o p r i a t e resources a v a i l a b l e when necessary. Although two n u r s i n g p e r s p e c t i v e s of p a r e n t a l p a r t i c i p a t i o n i n care emerged from the i n t e r v i e w data t h e r e i s no c o n f l i c t between these two groups of nurses. The 'our baby' group of nurses r e c o g n i z e t h a t the ' t h e i r baby' group p e r s p e c t i v e i s u s e f u l as a resource when d e a l i n g with some parents and r e l y upon them as resources when they run i n t o d i f f i c u l t i e s i n c e r t a i n s i t u a t i o n s . I t would be i n t e r e s t i n g t o d i s c o v e r who the s t a f f would i n d i c a t e as resource people f o r p a r e n t a l p a r t i c i p a t i o n i n c a r e . 4.14 Age. Table I I I , i n Appendix I I , re p r e s e n t s the ages of the s u b j e c t s . The range i n age of the twelve s u b j e c t s f e l l between t h i r t y and f o r t y - n i n e y e a r s . Seven s u b j e c t s were between the age of t h i r t y t o t h i r t y - n i n e , f i f t y - s e v e n percent from the ' our baby' group of nurses and f o r t y - t h r e e percent from the ' t h e i r baby' s u b j e c t s . F i v e s u b j e c t s were between t h e a g e o f f o r t y t o f o r t y - n i n e o f w h i c h f o r t y p e r c e n t w e r e f r o m t h e ' o u r b a b y ' g r o u p a n d s i x t y p e r c e n t f r o m t h e ' t h e i r b a b y ' g r o u p . T h e s a m p l e s i z e o f t h i s g r o u p (n=12) i s s m a l l a n d t h e n u r s e s d i d n o t r e p r e s e n t a l l o f t h e a g e g r o u p s i n n u r s i n g w h i c h s t r e t c h e s f r o m n i n e t e e n t o s i x t y - f i v e y e a r s o f a g e . T h e r e i s l i t t l e d i f f e r e n c e i n a g e d i s t r i b u t i o n o f t h e s u b j e c t s . H a l f o f t h e s u b j e c t s a r e t h i r t y t o t h i r t y - n i n e y e a r s o f a g e a n d t h e r e m a i n i n g h a l f b e t w e e n f o r t y t o f o r t y - n i n e y e a r s o f a g e . T h e r e i s l i t t l e a n n u a l s t a f f t u r n o v e r i n t h i s u n i t w h i c h may a c c o u n t f o r t h e m i n i m a l a g e d i s t r i b u t i o n . I n t h i s s t u d y t h e ' t h e i r b a b y ' n u r s e s t e n d t o b e o l d e r b u t t h e s a m p l e s i z e i s s m a l l . F o r t h e g r o u p o f s u b j e c t s , a g e d o e s n o t s e e m t o b e a c h a r a c t e r i s t i c t h a t c a n b e u s e d t o d e t e r m i n e n u r s e s who h a v e a f a m i l y - c e n t e r e d a p p r o a c h t o c a r e . 4 . 1 5 P a r e n t a l S t a t u s . T a b l e I V , i n A p p e n d i x I I , d e p i c t s t h e p a r e n t a l s t a t u s o f t h e t w e l v e s u b j e c t s i n t h e s t u d y . H a l f o f t h e s u b j e c t s i n t h i s s t u d y a r e p a r e n t s . The i n f o r m a t i o n c o l l e c t e d d u r i n g t h e i n t e r v i e w w h e n q u e s t i o n e d a b o u t p a r e n t a l s t a t u s h a s b e e n d i v i d e d i n t o t h e ' t h e i r b a b y ' a n d t h e ' o u r b a b y ' g r o u p s o f 75 n u r s e s . F i f t y - s e v e n p e r c e n t o f t h e ' o u r b a b y ' s u b j e c t s w e r e p a r e n t s w h i l e f o r t y - t h r e e p e r c e n t o f t h e ' t h e i r b a b y ' s u b j e c t s h a d c h i l d r e n o f t h e i r o w n . F o r t y - t h r e e p e r c e n t o f t h e ' o u r b a b y ' s u b j e c t s d i d n o t h a v e c h i l d r e n a s d i d s i x t y p e r c e n t o f t h e ' t h e i r b a b y ' g r o u p . O t h e r s t u d i e s o f p a r e n t a l p a r t i c i p a t i o n i n c a r e h a v e s u g g e s t e d t h a t n u r s e s who a r e p a r e n t s t h e m s e l v e s a r e m o r e l i k e l y t o e n c o u r a g e p a r e n t a l p a r t i c i p a t i o n i n c a r e t h a n n o n - p a r e n t s . T h e r e was n o e v i d e n c e t o s u p p o r t t h i s p o s i t i o n i n t h i s s t u d y . A s t h e s a m p l e i s s o s m a l l a n d t h e u n i t i s n o t r e p r e s e n t a t i v e o f a t y p i c a l t e r t i a r y i n t e n s i v e c a r e n u r s e r y , t h e n n o i n f e r e n c e c a n b e d r a w n b e t w e e n t h i s s t u d y ' s s u b j e c t s a n d t h o s e n u r s e s i n s i m i l a r s t u d i e s . P a r e n t a l s t a t u s c a n n o t b e u s e d , i n t h i s i n s t a n c e , a s a c h a r a c t e r i s t i c o f n u r s e s who w o u l d b e m o r e i n c l i n e d t o u s e a f a m i l y c e n t e r e d a p p r o a c h t o c a r e . 4 . 16 L e v e l o f N u r s i n g E d u c a t i o n . T a b l e V , i n A p p e n d i x I I , d e p i c t s t h e e d u c a t i o n a l n u r s i n g c o u r s e s c o m p l e t e d b y t h e s u b j e c t s . T h e r e w e r e t w e l v e s u b j e c t s i n t h i s s t u d y , t w o o f whom h a d a b a c c a l a u r e a t e n u r s i n g d e g r e e . F o u r h a d c o m p l e t e d a p o s t b a s i c c o u r s e i n n e o n a t a l n u r s i n g a n d 76 three of the same subjects had also completed a post basic course i n midwifery. The other six nurses had a diploma i n nursing. Previous research ( G i l l , 1985; Porter, 1979; Seidl and P i l l i t t e r i , (1967) indicated that nurses with higher education are more l i k e l y to incorporate the p r i n c i p l e s of family centered care when caring for children. In t h i s study there was no s p e c i f i c d i s t i n c t i o n between higher education and the incorporation of the p r i n c i p l e s of family centered care. Two of the nurses i n the 'our baby' group of nurses had completed a baccalaureate degree i n nursing (BSN), one was a c e r t i f i e d midwife (MID) and the other three members had a diploma i n nursing (DIP). From previous research the anticipated outcome would be that the BSN nurses would belong to the 'th e i r baby' group and display a family centered approach to parental p a r t i c i p a t i o n i n care. Two nurses from the 't h e i r baby' group had only a diploma i n nursing and no further educational preparation. As the sample size i s so small no inference about the l e v e l of nursing education and perspectives toward parental p a r t i c i p a t i o n i n care can be drawn i n t h i s study. Two of the nurses i n the ' t h e i r baby' group of s u b j e c t s had midwifery c r e d e n t i a l s and a l s o had completed a post b a s i c course i n n e o n a t a l n u r s i n g t i t l e d M & P on the t a b l e . One of the group had completed a post b a s i c course i n n e o n a t a l n u r s i n g while the remaining two members of the group had a diploma i n n u r s i n g (DIP). The major d i f f e r e n c e between the two groups i s t h a t t h r e e nurses who had completed a post b a s i c e d u c a t i o n a l course i n neonatology were i n the ' t h e i r baby' group. 4.17 Knowledge of Family Centered Care and Parent Teaching. Most of the s u b j e c t s l e a r n e d about f a m i l y c e n t e r e d care on the job. Two of the nurses from the 'our baby' group mentioned t h a t they had l e a r n e d the concept d u r i n g t h e i r nurse's t r a i n i n g (D, i n t e r v i e w , February 7, 1988; H, i n t e r v i e w , G, i n t e r v i e w , February 8, 1988) but the other f i v e s u b j e c t s had had to l e a r n on the job. One mentioned t h a t she had supplemented t h i s knowledge by r e a d i n g (G, i n t e r v i e w , February 21, 1988) . Four of the ' t h e i r baby' group had l e a r n e d about f a m i l y c e n t e r e d care on the job. The other s u b j e c t i n t h i s group mentioned t h a t she had l e a r n e d t h i s concept d u r i n g midwifery t r a i n i n g and r e i n f o r c e d i n a post b a s i c neonatal n u r s i n g course (B, i n t e r v i e w , February 6, 1988). 78 Parent t e a c h i n g s k i l l s were a l s o l e a r n e d on the job which i s a r e f l e c t i o n of the minimal amount of time spent i n a m a t e r n i t y r o t a t i o n d u r i n g nurses' t r a i n i n g . Two of the 'our baby' s u b j e c t s s t a t e d t h a t they had l e a r n e d parent t e a c h i n g on the job i n the agency where the study took p l a c e . One of these s u b j e c t s went on t o say t h a t most of her s k i l l s were developed "through t r i a l and e r r o r and r o l e modeling (A, i n t e r v i e w , February 18, 1988). The other of these two s u b j e c t s s a i d t h a t she taught i n her "own way u s i n g t r i a l and e r r o r and watching her peers" (D, i n t e r v i e w , February 7, 1988) . Two members of t h i s group s a i d they had l e a r n e d parent t e a c h i n g s k i l l s i n an o r i e n t a t i o n program t o the s p e c i a l care nursery where they were employed (K, i n t e r v i e w , February 9, 1988; L, i n t e r v i e w , February 7, 1988). Another s a i d she had developed her s k i l l s on the job (G, i n t e r v i e w , February 21, 1988). Only one member of the 'our baby' group s a i d she had l e a r n e d a l i t t l e d u r i n g her undergraduate degree program, but mainly on the job (H, in t e r v i e w , February 8, 1988) . A l l but one of the nurses i n the ' t h e i r baby' group mentioned t h a t they had l e a r n e d p a r e n t i n g s k i l l s i n the u n i t where the study took p l a c e . Three of the nurses (B, i n t e r v i e w , February 6, 1988; C, i n t e r v i e w , February 4, 1988; I, i n t e r v i e w , February 12, 1988) mentioned t h a t they used the head nurse as a r o l e model f o r parent t e a c h i n g as w e l l as some of t h e i r p e e r s. One nurse i n t h i s group s a i d she had l e a r n e d parent t e a c h i n g s k i l l s at i n s e r v i c e i n one h o s p i t a l where she had worked (E, i n t e r v i e w , February 12, 1988). The f i n a l member of t h i s group s a i d she had l e a r n e d the s k i l l through "common sense and her own p a r e n t i n g " (J, i n t e r v i e w , February 14, 1988) . Most of the s u b j e c t s had been i n t r o d u c e d t o the concept of f a m i l y c e n t e r e d care on the job and through t h e i r own experience developed parent t e a c h i n g s k i l l s . The head nurse a c t e d as a r o l e model and, t h e r e f o r e , through t h i s example nurses were encouraged t o c o n s i d e r the needs of p a r e n t s . 4.18 Experience of Nursing C h i l d r e n . The working experience of the s u b j e c t s with p e d i a t r i c and neonatal n u r s i n g ranged from f i v e t o twenty-one y e a r s . The range of the 'our baby' nurses was from f i v e t o nin e t e e n years e x p e r i e n c e . The ' t h e i r baby' range of experience was from seven t o twenty-one y e a r s . There was no s i g n i f i c a n t d i f f e r e n c e i n the working experience of the two groups. 80 4 . 1 9 Summary o f R e s e a r c h Q u e s t i o n T w o . The d e v e l o p m e n t o f n u r s e s ' p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n c a r e c a n n o t b e u n d e r s t o o d b y t h e s t r u c t u r a l v a r i a b l e s u s e d i n t h i s s t u d y . P r e v i o u s r e s e a r c h h a s d e m o n s t r a t e d t h a t n u r s e s o f a c e r t a i n a g e g r o u p , o f h i g h e r e d u c a t i o n a n d who a r e p a r e n t s a r e m o r e l i k e l y t o a d o p t a f a m i l y c e n t e r e d a p p r o a c h t o c a r e . T h e r e was n o e v i d e n c e i n t h i s s t u d y t h a t t h e r e i s a n y s i g n i f i c a n c e t o t h e a g e o r p a r e n t a l s t a t u s o f t h e s u b j e c t s when c o n s i d e r i n g t h e d e v e l o p m e n t o f p e r s p e c t i v e s , b u t t h e r e was a d i f f e r e n c e u p o n c o n s i d e r a t i o n o f e d u c a t i o n a l l e v e l . The t w o s u b j e c t s w i t h a b a c c a l a u r e a t e d e g r e e i n n u r s i n g w e r e members o f t h e ' o u r b a b y ' g r o u p . T h i s r e s u l t i s d i f f e r e n t f r o m w h a t p r e v i o u s s t u d i e s h a v e i n d i c a t e d . T h i s s t u d y was c o n d u c t e d o n o n e s i t e w i t h a s m a l l s a m p l e s i z e w h i c h c o u l d a c c o u n t f o r t h e d i f f e r e n c e i n e x p e c t e d o u t c o m e s i n p r o f e s s i o n a l a n d p e r s o n a l c h a r a c t e r i s t i c s o f t h e n u r s e s . The d e v e l o p m e n t o f n u r s i n g p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n c a r e i n t h e a r e a s o f w o r k l o a d , a c c o u n t a b i l i t y a n d r e s o u r c e s d i d d e m o n s t r a t e some s i m i l a r i t i e s a n d d i f f e r e n c e s i n p e r s p e c t i v e o f t h e t w o g r o u p s . I n t h e a r e a o f 81 w o r k l o a d t h e ' t h e i r b a b y ' n u r s e s d e s c r i b e d p a r e n t a l p a r t i c i p a t i o n a s a p o s i t i v e c o n t r i b u t i o n t h a t a s s i s t e d t h e n u r s e s t o d e l i v e r c a r e . T h e ' o u r b a b y ' n u r s e s f o u n d t h a t p a r e n t a l p a r t i c i p a t i o n i n c a r e a d d e d t o t h e w o r k l o a d a s t h e y saw t h a t t h e t i m e t h e y s p e n t w i t h p a r e n t s was a n a d d e d r e s p o n s i b i l i t y . A l l o f t h e s u b j e c t s a g r e e d t h a t a c c o u n t a b i l i t y d i d n o t i n f l u e n c e p r a c t i c e when i n v o l v i n g p a r e n t s i n c a r e . The n u r s e s s a i d t h a t t h e r e w e r e a p p r o p r i a t e r e s o u r c e s a v a i l a b l e t o t h e m w h e n p a r e n t s d i d p a r t i c i p a t e i n c a r e . The c o n c e p t o f f a m i l y c e n t e r e d c a r e f o r t h e m o s t p a r t was l e a r n e d o n t h e j o b b y members o f b o t h g r o u p s o f n u r s e s . E a c h d e v e l o p e d t h e i r own p e r s p e c t i v e m a i n l y b y e x a m p l e f r o m p e e r s o r t h r o u g h t r i a l a n d e r r o r . S k i l l s o f t e a c h i n g p a r e n t s t o p a r t i c i p a t e i n c a r e w e r e a l s o l e a r n e d o n t h e j o b a n d i t i s i n t e r e s t i n g t o n o t e t h a t t h e r e a r e t w o d i f f e r e n t a p p r o a c h e s w h i c h e x i s t s i d e b y s i d e i n t h e n u r s e r y . The h e a d n u r s e e n c o u r a g e s p a r e n t s t o p a r t i c i p a t e i n c a r e a n d p r o m o t e s f a m i l y c e n t e r e d c a r e a n d i s u s e d a s a r o l e m o d e l b y some o f t h e members o f t h e ' t h e i r b a b y ' g r o u p . T h e s e t w o p e r s p e c t i v e s o f c a r e a r e m o r e c l e a r l y d e m o n s t r a t e d i n t h e a c t i v i t i e s i n t h e u n i t r a t h e r t h a n t h e n u m b e r o f y e a r s i n v o l v e d i n n u r s i n g 82 c h i l d r e n o r s t r u c t u r a l v a r i a b l e s o f n u r s e s . The c o n c l u s i o n s o f t h i s s t u d y w i l l b e d i s c u s s e d i n t h e n e x t c h a p t e r . 83 C H A P T E R V D I S C U S S I O N T h i s c h a p t e r w i l l d i s c u s s t h e c o n c l u s i o n s d r a w n f r o m t h e d a t a . The t w o n u r s i n g p e r s p e c t i v e s w i l l b e d i s c u s s e d i n r e l a t i o n t o t h e r e s e a r c h q u e s t i o n s . I m p l i c a t i o n s f o r n u r s i n g p r a c t i c e o f h i r i n g , o r i e n t a t i o n a n d s t a f f d e v e l o p m e n t i n t h e l i g h t o f t h e r e s u l t s o f t h i s s t u d y a r e d i s c u s s e d . S u g g e s t i o n s f o r n u r s i n g e d u c a t i o n a n d f u r t h e r r e s e a r c h r e g a r d i n g p a r e n t a l p a r t i c i p a t i o n i n c a r e a r e i n c l u d e d . 5.1 N u r s i n g P e r s p e c t i v e s T h e d a t a c o l l e c t e d w i t h r e s p e c t t o r e s e a r c h q u e s t i o n o n e d e m o n s t r a t e t h a t t h e r e a r e t w o m a i n p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n t h e c a r e o f p r e t e r m i n f a n t s . One g r o u p o f n u r s e s ( ' t h e i r b a b y ' ) h a v e a d o p t e d a f a m i l y c e n t e r e d a p p r o a c h t o c a r e w h i l e t h e r e s t o f t h e s u b j e c t s ( ' o u r b a b y ' ) m a i n t a i n a t r a d i t i o n a l n u r s i n g a p p r o a c h . T h e d a t a c o l l e c t e d i n t h i s s t u d y s h o w t h a t t h e t w o g r o u p s h a v e n o d i s t i n c t p e r s o n a l 84 c h a r a c t e r i s t i c s t h a t may be used to c l a r i f y which nurses would f a l l i n t o 'our baby' or ' t h e i r baby' groups. T h i s f i n d i n g d i f f e r s from the study by Dunn (1978) which found age to be s i g n i f i c a n t and the s t u d i e s by G i l l (1985) and S e i d l (1969) which found p a r e n t a l s t a t u s t o be s i g n i f i c a n t i n the development of a p e r s p e c t i v e of p a r e n t a l p a r t i c i p a t i o n i n c a r e . Other s t u d i e s , a l s o conducted i n the U n i t e d S t a t e s , t h a t have surveyed n u r s i n g a t t i t u d e s towards p a r e n t a l p a r t i c i p a t i o n i n care have i n d i c a t e d t h a t nurses with h i g h e r education were more l i k e l y t o i n v o l v e parents i n care (Porter, 1979; G i l l 1985; S e i d l and P i l l i t t e r i , 1967; S e i d l , 1969) . T h i s was not demonstrated i n t h i s study as two nurses with b a c c a l a u r e a t e p r e p a r a t i o n had an 'our baby' p e r s p e c t i v e and two members of the ' t h e i r baby' s u b j e c t s had no f u r t h e r n u r s i n g courses other than a diploma. Three nurses i n c l u d e d i n t h i s study had completed a post b a s i c neonatology course and were members of the ' t h e i r baby' group. T h i s f i n d i n g c o u l d be a n t i c i p a t e d as these nurses were motivated to take f u r t h e r e d u c a t i o n i n t h e i r f i e l d of e x p e r t i s e and a l l t h r e e had been i n neonatal n u r s i n g f o r more than t e n years b e f o r e they took the course. The l e v e l of n u r s i n g e d u c a t i o n of the s u b j e c t s i n t h i s study cannot be 85 u s e d t o p r e d i c t w h i c h n u r s e s w o u l d h a v e a f a m i l y c e n t e r e d a p p r o a c h t o c a r e . The w o r k s e t t i n g h a s a l i m i t e d i m p a c t o n t h e n u r s e s ' p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n c a r e . T h e p e r s p e c t i v e s o f t h e members o f t h e t w o g r o u p s ' w e r e d e m o n s t r a t e d b y t h e r e s p o n s e s t h e y made t o t h e q u e s t i o n o f a c c o u n t a b i l i t y a n d w o r k l o a d . The t w o g r o u p s a g r e e d t h a t t h e y h a d l i t t l e p r o b l e m w i t h p a r e n t a l p a r t i c i p a t i o n b u t f o r d i f f e r e n t r e a s o n s a s d i s c u s s e d i n c h a p t e r f o u r . W o r k l o a d w a s a n a r e a w e r e t h e r e was a d i f f e r e n c e i n p e r s p e c t i v e . The ' o u r b a b y ' n u r s e s s a i d t h a t p a r e n t s i n c r e a s e d t h e w o r k l o a d . The i s s u e o f p a r e n t a l p a r t i c i p a t i o n i n c a r e seems t o b e o n e o f c o n t r o l . T h i s g r o u p b e l i e v e s t h a t p a r e n t s h a v e t o b e s u p e r v i s e d a n d t h e r e b y t h e ' o u r b a b y ' g r o u p o f n u r s e s m a i n t a i n c o n t r o l o f c a r e . I f t h e s e n u r s e s a r e b u s y a n d n o t a v a i l a b l e t o s u p e r v i s e , t h e p a r e n t s a r e l e s s l i k e l y t o b e i n v o l v e d i n c a r e b e c a u s e t h e n u r s e w o u l d l o s e c o n t r o l a n d t h i s a d d s t o t h e w o r k l o a d . On t h e o t h e r h a n d , t h e ' t h e i r b a b y ' n u r s e s b e l i e v e t h a t t h e p a r e n t s c o n t r i b u t i o n t o c a r e i s a s a p p r o p r i a t e a s t h e i r own a n d t h e r e f o r e r e d u c e s w o r k l o a d . 86 5.2 Family Centered Care Versus the Inner Sanctum The two perspectives described i n t h i s study are consistent with the development of neonatology. The expansion of neonatal knowledge r e s u l t i n g from an increase i n neonatal technology has had a great impact on the nursing s t a f f . Nurses became responsible for using a l l of the technological machinery necessary i n the care of acutely sick infants. Concurrently, perspectives of family centered care were incorporated into the philosophy of neonatal intensive care units. Incorporation of family centered care i n the special care unit i n t h i s study has resulted i n a change i n perspective from the guardian of neonates i n an 'inner sanctum' for the ' t h e i r baby' nurses. The 'our baby' group wish to maintain the status quo of previous years by l i m i t i n g parental p a r t i c i p a t i o n i n care. It i s i n t e r e s t i n g that these two groups practice side by side with l i t t l e obvious c o n f l i c t between them. The 'our baby' group of nurses maintain control of t h e i r nursing practice i n the h i e r a r c h i c a l hospital structure by l i m i t i n g parental p a r t i c i p a t i o n i n care. Parents are viewed as an added dimension to the care of the baby and not an i n t e g r a l part of neonatal nursing. These nurses f i n d i t easier to practice s t r i c t l y within the guidelines of established 87 p o l i c i e s and procedures and view changes i n the status quo, such as a change i n the v i s i t i n g p olicy, as having a negative impact for nursing s t a f f , the idea of the inner sanctum when they are the p r i v i l e g e d few and the most important caregiver in charge of the preterm infant p r e v a i l s . Certain aspects of family centered care have been incorporated into the 'our baby' nurses' practice but with r e s t r i c t i o n s described i n chapter four of t h i s study. The ' t h e i r baby' group of nurses have questioned the doctrines of neonatal care and have sought ways to expand t h e i r practice to include new concepts and i n d i v i d u a l i z e care i n s p e c i f i c circumstances and within certain l i m i t a t i o n s . These nurses completed a process od change from what they learned i n nursing school about family p a r t i c i p a t i o n i n a neonatal nursery. Sixty percent of the 'their baby' subjects are aged between forty and forty-nine years and would have experienced the 'inner sanctum' when they began nursing i n a neonatal unit. Why these nurse changed from a perspective of guardian of neonates to an advocate of family centered care could be the basis of another study. 88 5.3 I m p l i c a t i o n s f o r N u r s i n g P r a c t i c e 5.3.1 H i r i n g I f f a m i l y c e n t e r e d c a r e i s an i m p o r t a n t component o f n e o n a t a l n u r s i n g c a r e t h e head nurse o f a s p e c i a l c a r e n u r s e r y c o u l d use t h e r e s u l t s o f t h i s s t u d y t o d e t e r m i n e whether a n u r s e would a c t i v e l y i n v o l v e p a r e n t s i n t h e c a r e o f t h e i r b a b i e s . D u r i n g a pre-employment i n t e r v i e w t h e head nurse c o u l d e x p l o r e a p p l i c a n t s ' p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n c a r e . T h i s c o u l d be a c c o m p l i s h e d by o u t l i n i n g n u r s i n g a c t i v i t i e s where p a r e n t s a r e i n v o l v e d i n c a r e e.g. i n f a n t f e e d i n g . From t h e r e s u l t s o f t h i s s t u d y one o f t h e a r e a s where n u r s i n g p e r s p e c t i v e s would become apparent was i n t h e a r e a o f b r e a s t f e e d i n g , a n o t h e r t o p i c c o u l d be w o r k l o a d and how n u r s e s p e r c e i v e p a r e n t a l p a r t i c i p a t i o n i n c a r e when t h e u n i t i s busy. However, g i v e n t h e c r i t i c a l n u r s i n g s h o r t a g e t h e employer has l i t t l e c h o i c e i n h i r i n g new s t a f f and i s o f t e n c o m p e l l e d t o h i r e n u r s e s who have t h e most e x p e r i e n c e no m a t t e r what p e r s p e c t i v e t h e y h o l d towards p a r e n t a l p a r t i c i p a t i o n i n c a r e . 5.3.2 O r i e n t a t i o n From t h e r e s u l t s o f pre-employment i n t e r v i e w an i n d i v i d u a l i z e d o r i e n t a t i o n program c o u l d be d e s i g n e d w i t h t h e emphasis on approaches t o p a r e n t a l p a r t i c i p a t i o n i n c a r e . One o f t h e s t a f f 89 who has a fa m i l y centered p e r s p e c t i v e could be a preceptor f o r the new s t a f f member to demonstrate h i s / h e r approach t o p a r e n t a l p a r t i c i p a t i o n i n care. S p e c i a l emphasis should be placed on e v a l u a t i n g the new employee's pe r s p e c t i v e when d e a l i n g with parents. Nurses who d i s p l a y an 'our baby' pe r s p e c t i v e should be given feedback and encouraged to develop and implement a more f a m i l y centered approach when d e a l i n g with parents i n a s p e c i a l care nursery. One approach to feedback f o r these nurses could be based on t h e i r b e l i e f of who i s i n c o n t r o l of care, themselves or the parents. I t i s d i f f i c u l t t o change behavior but those w i l l i n g t o consider t h e i r own b e l i e f of c o n t r o l may be s t i m u l a t e d t o examine t h e i r p e r s p e c t i v e of p a r e n t a l p a r t i c i p a t i o n and, perhaps, modify t h e i r behavior. P e r s p e c t i v e s of p a r e n t a l responses t o the b i r t h of a preterm i n f a n t and how t h i s impacts upon i n t e r a c t i o n s between parents and nurses should be discussed. Coping techniques t h a t the preceptor f i n d s u s e f u l f o r d e a l i n g w i t h d i f f i c u l t p e r s o n a l i t i e s and s i t u a t i o n s could be addressed during the o r i e n t a t i o n program. 5 . 3 . 4 S t a f f Development The major problem i d e n t i f i e d i n t h i s study i s th a t nursing s t a f f have f i r m l y entrenched p e r s p e c t i v e s of p a r e n t a l p a r t i c i p a t i o n i n c a r e . The s h o r t e s t l e n g t h o f employment i n n e o n a t a l n u r s i n g o f t h e s u b j e c t s i n t h i s s t u d y i s f i v e y e a r s w h i l e o t h e r s t a f f have been n u r s i n g neonates f o r over twenty y e a r s . Nurses have i n c o r p o r a t e d t h e 'our baby' p e r s p e c t i v e i n t o d a i l y p r a c t i c e f o r many y e a r s and c o n s i d e r t h e m s e l v e s t o be s a f e and c a r i n g p r a c t i o n e r s o f p r e t e r m neonates. Changing a p e r s p e c t i v e i s not an easy t a s k e s p e c i a l l y when a p e r s o n does not i d e n t i f y t h i s t o be a problem. The p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n o f t h e 'our baby' group a r e based i n a deep s e a t e d need t o be i n c o n t r o l o f c a r e . I t would be i n t e r e s t i n g t o e x p l o r e o t h e r a s p e c t s o f t h e s e n u r s e s ' p r o f e s s i o n a l and p e r s o n a l l i f e t o d i s c o v e r i f t h e same sense of c o n t r o l i s r e f l e c t e d i n t h e i r r e l a t i o n s h i p w i t h t h e i r p e e r s , r e l a t i v e s and f r i e n d s . The head nurse c o u l d e x p l o r e n u r s e s ' p e r s p e c t i v e s o f c o n t r o l on an i n d i v i d u a l b a s i s t o a s s i s t them t o i d e n t i f y how t h i s i n f l u e n c e s t h e i r p r a c t i c e i n t h e a r e a o f f a m i l y c e n t e r e d c a r e . The head n u r s e c o u l d s t r e s s t h e importance o f f o s t e r i n g a h e a l t h y p a r e n t c h i l d r e l a t i o n s h i p i n t h e c a r e o f p r e t e r m i n f a n t s and how n e o n a t a l n u r s e s a re i n a prime p o s i t i o n t o promote t h e growth o f t h e s e r e l a t i o n s h i p s . P a r e n t s a r e i n f l u e n c e d by n u r s e s ' p e r s p e c t i v e s towards them and l e a r n t o 91 care for t h e i r baby by example. If parents f e e l that they are treated l i k e children by the 'our baby' nurses because of t h e i r need to control care then they w i l l not develop appropriate parenting s k i l l s i n the special care nursery. Inservice programs that discuss family centered care, with emphasis on parental p a r t i c i p a t i o n could be offered but t r a d i t i o n a l l y the people who most require a change i n perspective do not consider t h i s topic to be of value to them. Inservive instructors usually f i n d that they are preaching to the converted. Innovative teaching methods to explore nursing perspectives of parental p a r t i c i p a t i o n i n care could i d e n t i f y the issue of control and participants should be given techniques to a s s i s t them i n t h i s process. The head nurse should support the inservice and s t a f f who have a an 'our baby' perspective to parental p a r t i c i p a t i o n i n care should be encouraged to attend, at these sessions a consensus of the nurses' perspectives could be used to develop guidelines for parental p a r t i c i p a t i o n i n care i n the unit. Follow up sessions to discuss the success and f a i l u r e of these guidelines would be es s e n t i a l for further s t a f f development. 92 H o s p i t a l s s h o u l d b e e n c o u r a g e d t o e x a m i n e t h e w o r k s e t t i n g , p h i l o s o p h y a n d s t a n d a r d s o f c a r e t h a t i n f l u e n c e f a m i l y c e n t e r e d c a r e . W o r k a s s i g n m e n t s s h o u l d a l l o w f l e x i b i l i t y f o r s p e c i f i c n e e d s o f p a r e n t s when p a r t i c i p a t i n g i n c a r e o r i n n e e d o f c o u n s e l l i n g . The h e a d n u r s e c o u l d u s e t h e d e v e l o p e d g u i d e l i n e s f o r p a r e n t a l p a r t i c i p a t i o n a s a b a s i s f o r p e r f o r m a n c e a p p r a i s a l a n d t h o s e s t a f f w i t h a n ' o u r b a b y ' p e r s p e c t i v e w o u l d b e g i v e n s p e c i f i c o b j e c t i v e s t o a c c o m m o d a t e a c h a n g e i n t h e i r b e h a v i o r i f t h e s t a f f w i s h s u c h a c h a n g e . 5.4 N u r s i n g e d u c a t i o n T h e r e s u l t s o f t h i s s t u d y c o u l d b e s h a r e d w i t h n u r s i n g e d u c a t i o n a l i n s t i t u t e s t o e n c o u r a g e t h e m t o e x p l o r e f a m i l y c e n t e r e d c a r e a n d p a r e n t a l p a r t i c i p a t i o n i n c a r e d u r i n g t h e c o u r s e o f t h e p r o g r a m . N u r s e e d u c a t o r s s h o u l d b e e n c o u r a g e d t o e x p l o r e t h e i r own p e r s p e c t i v e s o f f a m i l y c e n t e r e d c a r e s o t h a t t h e y c o u l d p r o m o t e a ' t h e i r b a b y ' p e r s p e c t i v e t o w a r d s p a r e n t a l p a r t i c i p a t i o n a n d f u r t h e r e s t a b l i s h a c o u r s e o n t h e n e e d s o f a f a m i l y e x p e r i e n c i n g t h e b i r t h o f a c h i l d , i n a l l e n t r y l e v e l n u r s i n g p r o g r a m s . A l t h o u g h t h e r e i s l i m i t e d o r n o c l i n i c a l e x p e r i e n c e f o r n u r s i n g s t u d e n t s i n a s p e c i a l c a r e n u r s e r y a n a s s i g n m e n t w i t h p a r e n t s o f a p r e t e r m i n f a n t c o u l d b e i n c l u d e d i n t h e c o u r s e , t h i s a s s i g n m e n t c o u l d e x p l o r e t h e n e e d s o f 93 p a r e n t s w h e n p a r t i c i p a t i n g i n c a r e a n d a l s o t h e i r e x p e r i e n c e i n t h e s p e c i a l c a r e n u r s e r y w i t h n u r s i n g s t a f f . The s t u d e n t s c o u l d e x p l o r e t h e t w o p e r s p e c t i v e s o f c a r e t o l e a r n a b o u t f a m i l y c e n t e r e d c a r e . 5 . 5 F u r t h e r R e s e a r c h R e c o m m e n d a t i o n s f o r f u r t h e r s t u d y c o u l d i n c l u d e i n v e s t i g a t i n g p a r e n t a l r e s p o n s e s t o n u r s i n g s t a f f who h o l d a ' t h e i r b a b y ' a n d ' o u r b a b y ' p e r s p e c t i v e o f p a r e n t a l p a r t i c i p a t i o n i n c a r e . The ' o u r b a b y ' p e r s p e c t i v e c o u l d b e e x p l o r e d t o d i s c o v e r why n u r s e s w i t h s u c h a p e r s p e c t i v e n e e d t o m a i n t a i n c o n t r o l o f c a r e i n r e g a r d t o p a r e n t a l p a r t i c i p a t i o n . I t w o u l d b e o f i n t e r e s t t o d i s c o v e r why t h e ' o u r b a b y ' n u r s e s h o l d s u c h a p e r s p e c t i v e a n d d e t e r m i n e t h e o r i g i n o f t h i s p e r s p e c t i v e . A n o t h e r s t u d y c o u l d l o o k a t n u r s i n g p r o g r a m s t o d e t e r m i n e w h e t h e r p e r s p e c t i v e s o f f a m i l y c e n t e r e d c a r e a r e e s t a b l i s h e d i n a n e d u c a t i o n a l s e t t i n g . P a r e n t s ' r e a c t i o n s t o t h e t w o n u r s i n g p e r s p e c t i v e s c o u l d b e t h e s u b j e c t o f a n o t h e r s t u d y . T h i s s t u d y c o u l d b e r e p e a t e d i n o t h e r s e c o n d a r y a n d t e r t i a r y n e o n a t a l i n t e n s i v e c a r e u n i t s t o d e t e r m i n e i f t h e r e a r e t h e same o r d i f f e r e n t n u r s i n g p e r s p e c t i v e s o f p r e n t a l p a r t i c i p a t i o n i n t h e c a r e o f p r e t e r m i n f a n t s . 94 REFERENCES American P y c h o l o g i c a l A s s o c i a t i o n . (1990) . P u b l i c a t i o n Manual  of the American P v c h o l o q i c a l A s s o c i a t i o n T h i r d E d i t i o n . Washington, D.C. Author. Beaton J.L. 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Dimensions i n He a l t h S e r v i c e , .6, 25-31. Robinson, G. C , C l a r k e , H.F. (1980). The H o s p i t a l Care of  C h i l d r e n . A Review of Contemporary Issues. New York: Oxford U n i v e r s i t y P r e s s . S e i d l , F.W. (1969). P e d i a t r i c n u r s i n g personnel and p a r e n t a l p a r t i c i p a t i o n , a study i n a t t i t u d e s . N ursing Research, 18, 40-44. S e i d l , F.W., P i l l i t t e r i , A. (1967). Development of an a t t i t u d e s c a l e on p a r e n t a l p a r t i c i p a t i o n . N ursing Research, 18, 71-73. Sheldon, R.E., Dominiak, P.S. (1980). The Expanding Role of  the Nurse i n Neonatal I n t e n s i v e Care. New York: Grune and S t r a t t o n . Thornton, J . , Berry, J . , Dal Santo, J . (1987). Neonatal i n t e n s i v e c a r e : the nurses' r o l e i n s u p p o r t i n g the f a m i l y . N u r s i n g C l i n i c s o f N o r t h A m e r i c a , 1 9 , 1 2 5 - 1 2 7 . 97 APPENDIX I Letter of i n i t i a l contact 95 Letter of consent 96 Consent at time of interview 97 Research instrument 98 98 L E T T E R OF I N I T I A L CONTACT U n i v e r s i t y o f B r i t i s h C o l u m b i a V a n c o u v e r B r i t i s h C o l u m b i a D e a r T h i s i s a n i n v i t a t i o n t o p a r t i c i p a t e i n r e s e a r c h a b o u t n u r s e s ' p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n t h e c a r e o f p r e t e r m b a b i e s i n t h e s p e c i a l c a r e n u r s e r y . P a r e n t a l p a r t i c i p a t i o n i s a n a s p e c t o f f a m i l y c e n t e r e d c a r e w h i c h r e q u i r e s i n t e r a c t i o n b e t w e e n n u r s e s a n d p a r e n t s f r o m w h i c h n u r s e s d e v e l o p p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n i n c a r e . H a v i n g b e e n i n v o l v e d w i t h S . C . N . s i n c e 1978 I am i n t e r e s t e d i n how t h i s a s p e c t o f t h e f a m i l y c e n t e r e d c a r e p h i l o s o p h y i s a p p r o a c h e d b y t h e n u r s i n g s t a f f . A t t h e p r e s e n t t i m e I am c o n d u c t i n g t h i s i n v e s t i g a t i o n o f N u r s e s ' P e r s p e c t i v e s o f P a r e n t a l P a r t i c i p a t i o n i n t h e C a r e o f P r e t e r m I n f a n t s i n a S p e c i a l c a r e n u r s e r y . T h i s s t u d y i s p a r t o f t h e r e q u i r e m e n t s f o r a M a s t e r ' s d e g r e e i n E d u c a t i o n a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a . Y o u r i n v o l v e m e n t i n t h i s s t u d y w i l l c o n t r i b u t e t o a n u n d e r s t a n d i n g o f n u r s e s ' p e r s p e c t i v e s o f p a r e n t a l p a r t i c i p a t i o n a n d t o a c o m p r e h e n s i o n o f n u r s e - p a r e n t r e l a t i o n s h i p s . I h a v e e n c l o s e d a c o p y o f t h e l e t t e r t o p r o s p e c t i v e s u b j e c t s a n d t h e r e s e a r c h i n s t r u m e n t w i t h t h i s l e t t e r , i h o p e t h a t y o u w i l l a g r e e t o h a v e t h i s s t u d y c o n d u c t e d i n y o u r a g e n c y . T h a n k y o u f o r y o u r t i m e a n d a t t e n t i o n t o t h i s r e q u e s t . I l o o k f o r w a r d t o h e a r i n g f r o m y o u . Y o u r s s i n c e r e l y N o r m a F o s t e r M a s t e r ' s s t u d e n t U . B . C . 99 L E T T E R OF CONSENT TO P E R S P E C T I V E STUDENTS U n i v e r s i t y o f B r i t i s h C o l u m b i a V a n c o u v e r B r i t i s h C o l u m b i a D e a r I am i n v i t i n g y o u t o c o n t r i b u t e t o a s t u d y o n p a r e n t a l p a r t i c i p a t i o n i n t h e c a r e o f p r e t e r m i n f a n t s . A s a n u r s e who c a r e s f o r n e o n a t e s a n d t h e i r p a r e n t s , y o u may s h a r e my i n t e r e s t i n t h e s u b j e c t . Y o u w i l l p r o v i d e v a l u a b l e i n s i g h t s i n t o t h i s a s p e c t o f n u r s i n g p r a c t i c e . I w i s h t o i n t e r v i e w y o u f o r o n e h o u r a n d t h e i n t e r v i e w w i l l b e t a p e r e c o r d e d . To a s s u r e a n o n y m i t y , y o u r name w i l l n o t b e r e q u e s t e d a s p a r t o f t h e i n t e r v i e w . N e i t h e r n u r s i n g o r h o s p i t a l a d m i n i s t r a t i o n w i l l k n o w w h e t h e r y o u p a r t i c i p a t e o r n o t i n t h i s s t u d y , s i n c e a n o n y m i t y i s b e i n g m a i n t a i n e d , y o u r i n v o l v e m e n t i n t h i s s t u d y w i l l i n n o way a f f e c t y o u r n u r s i n g e v a l u a t i o n o r j o b s t a t u s . S h o u l d y o u r e q u i r e a n y f u r t h e r i n f o r m a t i o n r e g a r d i n g t h i s s t u d y , p l e a s e c o n t a c t m e . Y o u may r e f u s e t o p a r t i c i p a t e o r w i t h d r a w f r o m t h e s t u d y a t a n y t i m e . I w i l l s h a r e t h e r e s u l t s o f t h i s s t u d y w i t h t h e s t a f f i n S . C . N . W o u l d y o u p l e a s e s i g h o n t h e d o t t e d l i n e b e l o w a n d r e t u r n t h i s l e t t e r i n t h e e n v e l o p p r o v i d e d b y J a n u a r y 2 3 , 1988 i f y o u c o n s e n t t o p a r t i c i p a t e i n t h e s t u d y . I w i l l c o n t a c t y o u t o a r r a n g e a n i n t e r v i e w a t y o u r c o n v e n i e n c e . Y o u r p a r t i c i p a t i o n i n t h i s s t u d y w i l l c o n t r i b u t e t o n u r s i n g k n o w l e d g e , c a r e a n d t h e p r o f e s s i o n . T h a n k y o u f o r y o u r c o o p e r a t i o n . Y o u r s s i n c e r e l y N o r m a F o s t e r M a s t e r ' s s t u d e n t U . B . C . I c o n s e n t t o p a r t i c i p a t e i n t h e s t u d y R . N . 100 CONSENT AT T I M E OF I N T E R V I E W I, c o n s e n t t o b e i n t e r v i e w e d i n r e g a r d t o t h e r e s e a r c h N u r s e s ' P e r s p e c t i v e s o f P a r e n t a l P a r t i c i p a t i o n i n t h e C a r e o f p r e t e r m I n f a n t s i n a S p e c i a l C a r e N u r s e r y . The i n t e r v i e w w i l l t a k e a p p r o x i m a t e l y o n e h o u r a n d w i l l b e t a p e r e c o r d e d , t o e n s u r e c o n f i d e n t i a l i t y t h e t a p e s w i l l b e e r a s e d f o l l o w i n g t r a n s c r i p t i o n . I w i l l b e a l l o w e d t o s t o p t h e i n t e r v i e w a t a n y t i m e , w i t h o u t p r e j u d i c e . S i g n a t u r e I n t e r v i e w e r D a t e 101 RESEARCH INSTRUMENT 1. What does p a r e n t a l p a r t i c i p a t i o n i n S.C.N, mean f o r you on a day to day b a s i s ? - e d u c a t i o n - d e c i s i o n making - p h y s i c a l a c t i v i t i e s 2. Approximately how many parents do you meet i n a normal working day? 3. During a normal working day how much of your time i s spent i n v o l v i n g parents i n care? 4. Can you e x p l a i n how you determine how much time t o spend with parents? - a c u i t y of care - l e n g t h of time i n f a n t has been i n the u n i t - d i f f e r e n t i a t e between a new admission and an i n f a n t ready f o r d i s c h a r g e . 5. Are t h e r e some parents you spend more time with than others? Can you e x p l a i n why? 6. What k i n d of i n t e r a c t i o n do parents have with t h e i r baby? - t o u c h i n g - t a l k i n g - e f f e c t of a c u i t y of c a r e . 7. What do you teach parents about i n f a n t behavior? 8. What do you teach parents about i n f a n t s t i m u l a t i o n ? 9. Do you d i s c u s s the f e e d i n g schedule with the parents? Can you e x p l a i n how you do t h i s . 10. Do you d i s c u s s d a i l y c a l o r i c and f l u i d requirements of the neonate? 11. Do the parents decide the time a baby should be fed? 12. What i s p a r e n t a l involvement i n b o t t l e feeding? 13. D e s c r i b e s i t u a t i o n s when mothers' b r e a s t feed. 14. Is the f e e d i n g schedule arranged t o accommodate p a r e n t a l 102 v i s i t s ? 15. What i n v o l v e m e n t s d o p a r e n t s h a v e i n g a v a g e f e e d i n g ? P l e a s e g i v e a n e x a m p l e . 16. How do p a r e n t s p a r t i c i p a t e i n t h e a d m i n i s t r a t i o n o f I . V . ' s ? 17. Do y o u a n t i c i p a t e t h a t p a r e n t s may b e c o m e i n v o l v e d i n t h i s a s p e c t o f c a r e ? P l e a s e e x p l a i n . 18. C a n y o u e x p l a i n how p a r e n t s b a t h e t h e i r b a b y . 19. Who d e c i d e s u p o n t h e b a t h i n g s c h e d u l e , t h e p a r e n t s o r y o u ? A r e t h e r e c i r c u m s t a n c e s w h e n p a r e n t s s h o u l d n o t b a t h e t h e i r b a b y ? P l e a s e e x p l a i n . 20. I f p a r e n t s c a n o n l y v i s i t i n t h e e v e n i n g w o u l d y o u a l l o w t h e m t o b a t h e t h e i r b a b y t h e n ? 21. Do p a r e n t s b r i n g g i f t s f o r t h e i r b a b y ? A r e t h e r e a n y l i m i t a t i o n s ? 22. Do p a r e n t s d e c i d e how a n d w h e n t o d r e s s t h e i r b a b y ? A r e t h e r e a n y l i m i t a t i o n s ? 23. What i n v o l v e m e n t d o p a r e n t s h a v e i n t h e c a r e o f a n e o n a t e r e q u i r i n g p h o t o t h e r a p y ? 24. Do y o u d i s c u s s t h e r e s u l t s o f b i l i r u b i n t e s t s w i t h p a r e n t s ? P l e a s e e x p l a i n . 25. What r o l e d o p a r e n t s h a v e g i v i n g m e d i c a t i o n s ? P l e a s e e x p l a i n . 26. How do y o u p l a n w i t h p a r e n t s f o r d i s c h a r g e ? 27. What p a r t o f p a r e n t a l p a r t i c i p a t i o n do y o u e n j o y t h e m o s t ? 28. What p a r t o f p a r e n t a l p a r t i c i p a t i o n i s t h e m o s t d i f f i c u l t f o r y o u ? 29. What e f f e c t h a s t h e new v i s i t i n g p o l i c y h a d u p o n y o u r c a r e ? 30. A r e t h e r e o t h e r p a r t s o f p a r e n t a l p a r t i c i p a t i o n I h a v e n o t m e n t i o n e d ? 103 31. Do y o u e n c o u r a g e b o t h p a r e n t s t o p a r t i c i p a t e i n c a r i n g f o r t h e i r b a b y ? P l e a s e e x p l a i n . 32. H a v e y o u a n y c o n c e r n s r e g a r d i n g a c c o u n t a b i l i t y w h e n p a r e n t s a r e i n v o l v e d i n t h e c a r e o f t h e i r c h i l d ? 33. What k i n d o f i n f l u e n c e d o e s w o r k l o a d h a v e o n p a r e n t a l p a r t i c i p a t i o n i n c a r e ? 34. A r e t h e r e r e s o u r c e s a v a i l a b l e w h e n y o u r e q u i r e a s s i s t a n c e w i t h p a r e n t a l p a r t i c i p a t i o n ? 35. A r e t h e r e a n y o t h e r f a c t o r s w h i c h may a f f e c t p a r e n t a l p a r t i c i p a t i o n i n c a r e ? 36. W o u l d y o u r e c o m m e n d a c h a n g e i n p o l i c y r e g a r d i n g p a r e n t a l p a r t i c i p a t i o n i n t h e c a r e o f p r e t e r m i n f a n t s i n S . C . N . ? N U R S I N G A T T R I B U T E S 37. A g e 20 - 29 30 - 39 40 - 49 50 - 59 38. P a r e n t a l s t a t u s - p a r e n t - n o n p a r e n t 39. E d u c a t i o n a . L e v e l o f e d u c a t i o n - d i p l o m a - b a c c a l a u r e a t e n u r s i n g - b a c c a l a u r e a t e n o n n u r s i n g - p o s t b a s i c n u r s i n g c o u r s e i . n e o n a t a l i i . p e d i a t r i c i i i . o b s t e t r i c s i v . m i d w i f e r y v . o t h e r b . W h e r e d i d y o u l e a r n t h e c o n c e p t o f f a m i l y c e n t e r e d c a r e i n a s p e c i a l c a r e n u r s e r y ? - n u r s i n g c o u r s e - c o n t i n u i n g e d u c a t i o n 104 - personal reading - other. Please specify - don't know c. Where did you learn the s k i l l s of involving parents i n care? - nursing course - continuing education - on the job. Please describe. 40. Number of years nursing children 0 - 5 6 - 1 0 1 1 - 1 5 1 6 - 2 0 21 - 25 105 APPENDIX I I T a b l e I I I 103 T a b l e IV 104 T a b l e V 105 106 AGE OF SUBJECTS TABLE III % OF SUBJECTS 80 r • -30-39 40-49 AGE OF SUBJECTS PARENTAL STATUS TABLE IV % OF SUBJECTS YES NO PARENTAL STATUS NURSING EDUCATION TABLE V % OF SUBJECTS BSN M & P PBN MID DIP CURRICULUM 

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