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IMPACT OF AN EDUCATIONAL INTERVENTION ON NURSES’ KNOWLEDGE
AND CARING BEHAVIOR FOR LATE PRETERM INFANTS
by
Francesca I. Onyejuruwa
A Dissertation Submitted to the Faculty of
The Christine E. Lynn College of Nursing
in Partial Fulfillment of the Requirements for the Degree of
Doctor of Philosophy
Florida Atlantic University
Boca Raton, Florida
May 2014
ii
© Copyright Francesca I. Onyejuruwa 2014
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ACKNOWLEDGEMENTS
First and foremost, I will like to give thanks to God for the love and support of
family and friends that has been given me through this journey. To my chair, Dr. Sharon
Dormire, I thank you for your patience, guidance, and support. This would not have been
completed without you.
To my dissertation committee, Dr. Ruth McCaffrey who saw my doubts,
recognized the potential, and encouraged me to pursue my goal. Dr. David Newman who
was a tremendous help with my research design, data collection method, and analysis. Dr.
Mira Sarsekeyeva, I appreciate you for your quiet support and encouragement.
To my husband Onuabuchi who almost gave up his beloved music to allow me
quiet study times until he discovered a more sophisticated headphone. I am grateful to my
daughter Buchi, my constant cheerleader, companion, and “sounding board.” My sons,
Chidi and Uzochi, for reassuring me in my periods of frustration.
My heartfelt thank you goes to the nurses who took the time out of their busy
schedules to participate in this study. This study would not have been completed without
your participation. To Cindy Rich-Rosenstein, Maureen Laighold, and Wendy Berman,
thank you for the joy of friendship and for your interest in my academic progress. To my
boss, Dr. Mary Roberts, who always has been there for me, I continuously give thanks to
God for your role in my life.
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ABSTRACT
Author: Francesca I. Onyejuruwa
Title: Impact of an Educational Intervention on Nurses’ Knowledge and Caring Behavior for Late Preterm Infants Institution: Florida Atlantic University
Dissertation Advisor: Dr. Sharon Dormire
Degree: Doctor of Philosophy
Year: 2014
The purpose of this study was to examine the effect of an educational intervention
using Swanson’s (1991) caring theory on (a) nurses’ knowledge and caring behavior to
late preterm infants (LPIs) and their families, and (b) the incidence of LPIs’ hospital
visits and readmission rates for hyperbilirubinemia and dehydration in the first 30 days of
life.
The study began with the initial testing of the two instruments used and there
were no inconsistencies identified in the content being measured. A convenient sample of
nursery and postpartum nurses was recruited from two hospitals within a healthcare
system. The nurses completed the consents and the surveys online via Survey Monkey®.
Instruments used in the survey included a demographic, knowledge, and caring
questionnaires.
The participants’ inclusion criteria were nurses who have: a) completed at least
one year experience working with well newborns, b) attended the educational
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intervention, and c) completed tests at the three intervals. SPSS for Windows (version 21)
was used to analyze data using statistical techniques and ANOVA repeated measures.
Study findings support improved knowledge for all participants; however, there
was decreased retention of knowledge noted one month later. There was a 37% increase
in knowledge from the baseline mean scores to the posttest mean scores (52% to 89%),
although there was a 20% knowledge decrease from the posttest to one month later (89%-
69%). There remained a true knowledge gain since knowledge increased between the
baseline measurements to the 1-month follow-up assessment (52% to 69%). Infant
outcomes related to hyperbilirubinemia and dehydration also demonstrated patterns of
improvement in the direction of statistical significance. The study added to the body of
nursing science regarding educational intervention as a tool in increasing nurses’
knowledge.
DEDICATION
To my parents
Evelyn Nwachi Chinye and Joseph Okonkwo Chinye (deceased)
Rest in Peace Papa
Your visions made this possible
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IMPACT OF AN EDUCATIONAL INTERVENTION ON NURSES’ KNOWLEDGE
AND CARING BEHAVIOR FOR LATE PRETERM INFANTS
LIST OF TABLES ............................................................................................................. xi
LIST OF FIGURES .......................................................................................................... xii
CHAPTER ONE. INTRODUCTION ................................................................................. 1
Purpose .................................................................................................................... 4
Background and Significance ................................................................................. 4
Statement of the Problem ........................................................................................ 7
Research Questions ................................................................................................. 9
Theoretical Framework ........................................................................................... 9
Knowing .................................................................................................... 10
Being With ................................................................................................ 12
Doing For .................................................................................................. 13
Enabling .................................................................................................... 13
Maintaining Belief .................................................................................... 14
Definition of Terms ............................................................................................... 16
Assumptions .......................................................................................................... 18
Summary ............................................................................................................... 19
CHAPTER TWO. LITERATURE REVIEW ................................................................... 21
Theory of Human Caring ...................................................................................... 21
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Risk Associated with the Late Preterm Infants ..................................................... 25
Morbidity and Mortality ........................................................................... 26
Hyperbilirubinemia (Jaundice) ................................................................. 29
Respiratory Distress .................................................................................. 32
Hypothermia and Hypoglycemia .............................................................. 35
Feeding Challenges ................................................................................... 37
Neurodevelopmental Issues ...................................................................... 39
Educational Intervention ....................................................................................... 42
Education in Caring Behaviors ................................................................. 45
Summary ............................................................................................................... 46
CHAPTER THREE. METHODOLOGY ......................................................................... 47
Research Design .................................................................................................... 48
The AWHONN Assessment and Care of the Late Preterm Infant ........... 50
The Caring Professional Scale .................................................................. 50
Outline for Educational Intervention .................................................................... 52
Study Method ........................................................................................................ 54
Sample ....................................................................................................... 55
Sampling Method ...................................................................................... 56
Setting ....................................................................................................... 57
Protection of Human Subjects .............................................................................. 57
Data Collection Procedures ................................................................................... 58
Study Data Analysis .............................................................................................. 60
Assumptions and Study Limitations ..................................................................... 64
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Summary ............................................................................................................... 65
CHAPTER 4. STUDY RESULTS .................................................................................... 66
Psychometric Analysis .......................................................................................... 66
Content Validity .................................................................................................... 67
Internal Consistency Reliability ............................................................................ 68
Description of the Participants .............................................................................. 71
Sample Characteristics .............................................................................. 71
Demographic Characteristics of Participants ............................................ 75
Primary Findings ................................................................................................... 78
Research Hypothesis 1 .............................................................................. 78
Research Hypothesis 2 .............................................................................. 79
Research Hypothesis 3 .............................................................................. 81
Research Hypothesis 4 .............................................................................. 82
Summary ............................................................................................................... 83
CHAPTER 5. INTERPRETATIONS AND DISCUSSIONS ........................................... 84
Discussion of Results ............................................................................................ 85
Research Questions and Interpretation ..................................................... 85
Fit with Theoretical Framework ........................................................................... 92
Limitations of the study ........................................................................................ 93
Implications for Nursing Education and Practice ................................................. 94
Recommendation for Future Research .................................................................. 96
Conclusion ............................................................................................................ 96
APPENDICES .................................................................................................................. 98
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Appendix A. AWHONN Permission .................................................................... 99
Appendix B. Swanson Permission ...................................................................... 101
Appendix C. Late Preterm Infant Knowledge Assessment Instrument (LPI-KI) ........................................................................................................ 102
Appendix D. Late Preterm Infant Caring Professional Scale (LPI-CPS) ........... 107
Appendix E. Bhutani’s Total Serum Bilirubin Nomogram ................................ 108
Appendix F. Expert Assessment of the Knowledge Instrument ......................... 110
Appendix G. Expert Assessment of the Caring Professional Scale .................... 112
Appendix H. PowerPoint Demonstration of Education Intervention ................. 113
Appendix I. FAU IRB Approval ......................................................................... 121
Appendix J. Health System IRB Approval ......................................................... 123
Appendix K. CNO Letters of Approval .............................................................. 125
Appendix L. Recruitment Flyer .......................................................................... 128
Appendix M. Informed Consent ......................................................................... 129
Appendix N. Demographic Tool ......................................................................... 133
REFERENCES ............................................................................................................... 135
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LIST OF TABLES
Table 1. Cronbach’s Alpha for Knowledge ...................................................................... 70
Table 2. Cronbach’s Alpha for Caring .............................................................................. 71
Table 3. Demographic Characteristics of Participants (N=72) ......................................... 76
Table 4. One-way Repeated Measures Analysis of Variance Investigating Change Over Time fromPretest to Post and One Month Follow-up for Knowledge and Caring ........................................................................................................................ 79
Table 5. Multiple Comparisons of Knowledge Change Over Time ................................. 80
Table 6. Multiple Comparisons of Caring Changes Over Time ....................................... 80
Table 7. Test of Changes in Hospital Visits and Readmissions from Before to After Educational Intervention ........................................................................................... 82
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LIST OF FIGURES
Figure 1. Design Study ..................................................................................................... 55
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CHAPTER ONE
INTRODUCTION
The American Academy of Pediatrics (AAP) and the American College of
Obstetrics and Gynecology (ACOG) have defined prematurity as an infant delivered
before 37 weeks of pregnancy (AAP/ACOG, 2012). According to Hauth (2006), the rate
of prematurity has increased over the past decade and reasons for the increase include
demographic transformation, increasing age of childbearing women, change in fertility
treatment, and increasing incidence of multiple births. In the United States, over 70% of
all preterm births and 9.1% of all births are late preterm infants (LPIs) (Hamilton, Martin,
& Ventura, 2006; Shaw, 2008). The LPI is defined as an infant who is delivered between
34-36.6/7 weeks post conception (Medoff-Cooper, Bakewell-Sachs, Buus-Frank, &
Santa-Donato, 2005; Raju, Higgins, Stark, & Leveno, 2006; Wang, Dorer, Fleming, &
Catlin, 2004). Although, the very preterm infant (<32 weeks) birth rate has remained
about the same for the past 20 years, the rate for those born late preterm has continued to
rise (Martin et al., 2006). Recently, the LPI has become the fastest growing subset of
newborns drawing significant professional interest (Davidoff et al., 2006). Increased
demand for assisted reproductive technology with an associated increased incidence of
multiple gestation pregnancies as well as increased incidence of Cesarean births are
contributing factors to the increased rate of LPIs (Mally, Bailey, & Hendricks-Munoz,
2010).
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Classification of premature infants into very early, early, and “late preterm”
subcategories differentiates their unique risks and morbidities. For the LPI, this
designation is particularly significant since their increased risk of morbidity compared to
their full term counterpart often is unrecognized (Engle, 2006). The LPIs have been
identified as needing extra nursing attention post delivery whereas in the past they have
been considered to be the same as full term infants (Jorgensen, 2008a; Shaw, 2008).
Findings from current research identifies the complications and risk that these group of
infants face include respiratory distress syndrome, hyperbilirubinemia, temperature
regulations, sepsis, feeding difficulties, and neurodevelopmental delays (Cleaveland,
2010; Lindstrom, Winbladh, Haglund, & Hjern, 2007; Mally et al., 2010). Further, LPI
births account for increased hospital costs due to the need for readmission of many of
these infants within 30 days of life (Burgos, Schmitt, Stevenson, & Phibbs, 2008; Meier,
Furman, & Degenhardt, 2007; Shapiro-Mendoza et al., 2008; Pados, 2007). Additionally,
LPIs require closer monitoring because they are developmentally and physically
immature and therefore experience more health challenges and higher mortality rates than
their full term counterparts (Engle, Tomashek, Wallman, & The Committee on Fetus &
Newborn, 2007). Moreover, infant mortality rates were three times higher for LPIs than
among their full term counterparts between 1995-2002 (Tomashek, Shapiro-Mendoza, &
Petrini, 2007).
It is important to note that the LPI is at a much higher risk for readmission in the
first 30 days of life than their full term counterparts due to high bilirubin levels, poor
feeding, and dehydration (Medoff-Cooper et al., 2005). With a paucity of research related
to the nursing care of LPIs, there is a need to educate health care providers on how to
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care for the LPI to improve outcomes. To meet this goal, perinatal nurses must be
prepared to evaluate the unique challenges these infants and their families face. As a
result, nurses will have the requisites needed to provide information regarding the needs
of the LPIs and their families as well as to promote better health and care for this group.
While acknowledging the importance of the acquisition of knowledge and skill to
professional practice, Brown (2011) recognized that there is a need to develop attitudes,
beliefs, and values central to the nurturing and caring nursing perspective. Therefore,
caring theory was used as a guide in this study. Using caring theory as an underlying
framework for the development and delivery of educational information enhanced the
nurses’ ability to identify the unique and individual needs of the LPIs and their families,
which is a precursor to quality and safe health care and enhanced outcomes. Ahern,
Corless, Davis, and Kwong (2011) identified that patients have more than a medical
focus and advocated for a more holistic approach to patient care that is based on a nursing
model. Watson (2008) posited that caring is a moral imperative in nursing and
encourages nursing interventions that foster human dignity through caring. Boykin and
Schoenhofer (2001) stated that the nurses’ intentional actions allow for the appreciation
of the individuality of each patient while seeking a better understanding of their
perspective. Using Swanson’s theory of caring as a framework through a nursing lens
provided a more holistic approach for enhancing outcomes. By translating theory into
practice, the nurses were able to actualize Swanson’s concepts by combining nursing
compassion (knowing and being with) and competence (doing for and enabling)
grounded in the culture of maintaining belief. The theory allowed for a patient-centered
focus as the LPI is viewed as a unique individual. The nursing intervention included
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actions that engage families in the LPI care, educating, and acknowledging families as
well as advocating for them in order to meet their needs.
Purpose
The purpose of this quasi-experimental repeated measures one group study was to
examine the effect of an educational intervention using Swanson’s (1991) caring theory
on: (a) the nurses’ knowledge regarding care provided to LPIs and their families, and (b)
the incidence of hospital visits and readmission rates of LPIs for hyperbilirubinemia and
dehydration in the first 30 days of life. The current medical mode was enhanced by the
application of a caring theory. Swanson’s theory of caring is comprehensive enough to
provide structure, which was needed for incorporating a nursing perspective in the
provision of care to the LPI and their families.
Background and Significance
Currently, there is a national epidemic of cesarean section (C/S) deliveries, with
some of these infants within the LPI range (Roth-Kleiner, Wagner, Bachmann, &
Pfenninger, 2003). Preterm delivery can occur spontaneously due to pregnancy
complications or to obstetrical intervention without pregnancy complication. The preterm
birth rates have risen by over 30% since 1981, and LPIs account for 12% of all preterm
births, with an estimated cost of care at $26 billion in 2005 (Institute of Medicine, 2006).
Further, in the United States, over 70% of all preterm births are LPIs, with hospital costs
increasing due to readmission within 30 days of life (Hamilton et al., 2006; Shapiro-
Mendoza, 2006; Shaw, 2008). Researchers noted that infant mortality rates were three
times higher among LPIs than their full term counterpart (Tomashek et al., 2007).
Additionally, these infants are more likely to be readmitted for inadequate glucose and
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bilirubin metabolism, regulation of breathing, temperature control, awake/alert behavior
states, and ineffective feeding (Medoff-Cooper et al., 2005; Meier et al., 2007).
Understanding the morbidity risks among LPIs will assist health care providers in
anticipating and managing the potential problems associated with this group. Currently,
there are no standardized nursing care guidelines for the care of this sub group. Using
standardized nursing care guidelines developed for full term infants with this vulnerable
population of infants may compromise their outcome as has been suggested in the
literature (Medoff-Cooper et al, 2005).
Despite an increased interest in the LPI and the lack of appropriate guidelines in
their care, it is surprising that little empirical research has been conducted from the
nursing care perspective. The Association of Women’s Health Obstetrics and Neonatal
Nurses (AWHONN) (2010) focused on evidence-based clinical guidelines in LPI care
and the AAP/ACOG (2012) has recommendations for the medical management of some
LPI high risk issues. Very few studies have focused on how to appropriately care for this
population of infants with emphasis on their specific needs. A knowledge-practice gap
still exists, and increased caregiver education remains a necessity. Therefore, the aim of
this study was to examine the effect of an educational intervention using a pre/post study
design on a single group of nursery and post partum nurses in the care of the late preterm
infant. The primary goal of the study was to explore the differences in the LPI knowledge
of the nursery and post partum nurse before and after an educational intervention.
AWHONN’s (2010) “Assessment and Care of the Late Preterm Infant: Evidence-based
clinical practice guideline” posttest was used as an assessment tool for the study. A
behavioral assessment tool based on Swanson’s theory of caring was used to evaluate the
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nursing management of the LPI. Permission to use the posttest as a knowledge
assessment tool was obtained from AWHONN (Appendix A) and permission to use the
modified version of the behavioral tool was obtained from the developer, Dr. Kristen
Swanson (Appendix B).
Swanson’s (1991) caring theory was used as a framework to guide this study.
“The implications of theories are often not readily apparent to practicing nurses, as a
result, theory-guided practice remains an ideal versus a reality in most organizations”
(Tonges & Ray, 2011, p. 374). Implementing Swanson’s theory of caring through an
educational intervention is an approach to actualize the concepts through nursing actions
towards the LPI and their families. These nursing actions are based on Swanson’s theory
of caring concepts of knowing, being with, doing for, enabling, and maintaining belief.
The theory provided nurses with a theoretical focus for individualized nursing care to the
LPI and their families.
The second objective of the study was to determine if there was a reduction in LPI
hospital visits and readmission rates one month after the educational intervention. It was
anticipated that nurses who are taught caring behaviors will communicate caring
behaviors to the LPIs and their families after the educational intervention. Nurses who are
knowledgeable about the care LPIs need will be better able to care for and properly
educate the family before the infant is discharged. As a result, it was anticipated that the
number of hospital visits and the readmission rates of the LPI due to complications such
as hyperbilirubinemia and dehydration, which can lead to a high cost of care, may be
reduced.
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Statement of the Problem
LPIs are neither mature enough to be cared for as full term babies in the regular
newborn nursery nor are they ill enough to be admitted to the Newborn Intensive Care
Unit (NICU). The LPIs present a challenge for the health care provider when deciding
placement for level of care. In anticipation of health problems, infants delivered at less
than 34 weeks are cared for in the NICU and those infants who are greater than 37 weeks
are cared for in the nursery or post partum units. The level of care for the 34-37 weeks
infant (LPI) is determined by the opinion of the health care provider (HCP) at time of
delivery, influenced by the available resources (beds and nurses). So while one hospital
may decide to care for these infants in a newborn nursery, another may provide care in
the NICU, and yet another may room this group of infants in with their mothers on a post
partum unit. Additionally, because these infants sometimes weigh and look like full term
newborns, health care professionals expect LPIs to act like full term infants. As a result,
they may not receive the level of observation, assessment, and precautionary care that
less mature infants receive (AWHONN, 2006). Yet, LPIs have greater numbers of post
birth problems than do full term infants (Escobar, Clark, & Greene, 2006). While
rooming in a post partum unit may promote maternal infant bonding and breast-feeding,
the LPI’s decreased length of stay contributes to the health care provider’s inability to
assess these infants or to teach parents how to read the infant’s cues. As a result, LPIs
tend to have more hospital visits and readmissions within the first 30 days of life than
their full term counterparts (Shapiro-Mendoza et al., 2006; Tomashek et al., 2006).
Educating health care professionals, particularly nurses, on the care of the LPIs
has been identified as a priority in improving outcomes (Baker, McGrath, Lawson,
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Liverman, & Cohen, 2009; Jorgensen, 2008b; Shaw, 2008). In 2005, the National
Institute of Child Health and Human Development of the National Institute of Health
invited a multidisciplinary team of experts to a workshop entitled “Optimizing Care and
Outcome of the Near Term Pregnancy and Near Term Newborn Infant.” This group
discussed the issue of the LPI being at risk for short and long term morbidities in contrast
to the term newborn (Bhutani, Johnson, Schwoebel, & Gennaro, 2006; Jain & Cheng,
2006; Young, Glasgow, Li, Guest-Warwick, & Stoddard, 2007). Additionally, a body of
literature has begun to emerge regarding the lack of knowledge in the area of
management of the LPI (AWHONN, 2006). Limited knowledge among nurses about how
to care for the LPI and how to identify the risks associated with this group of infants is
concerning to nurses, physicians, and families. Evidence suggests that there are many
ways to enhance access to such knowledge and expertise, including education of patients
and primary care givers (Institute of Medicine, 2006). The consensus among many post
partum and nursery nurses is that appropriate education not only will allow nursing staff
to better care for these infants but also will allow nurses to assist parents to prepare
adequately to independently care for the infant at home, thereby reducing the need for
hospital visits and readmissions (Shaw, 2008). Using a holistic approach through a caring
theory to uncover the needs of LPIs and families and to create a teaching-learning
intervention will provide nurses with the requisite needed to see each LPI as unique with
special requirements for assessment and management of their individual needs. As a
result, theses nurses will be able to assist the families of LPIs to understand the needs of
their infants and to provide the needed care at home to prevent excessive hospital visits
and readmissions.
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Research Questions
The research questions that were used to guide this inquiry were:
1. What is the effect of a late preterm infant educational intervention on
knowledge among practicing nursery and post partum nurses?
2. What is the effect of a late preterm infant educational intervention based on
Swanson’s theory on caring behaviors among practicing nursery and post
partum nurses?
3. What is the effect of a late preterm infant educational intervention program on
the incidence of hospital visits and readmission rate for hyperbilirubinemia in
the late preterm infant during the first 30 days of life?
4. What is the effect of a late preterm infant educational intervention program on
the incidence of hospital visits and readmission rate for dehydration in the late
preterm infant during the first 30 days of life?
Theoretical Framework
Swanson’s (1991) caring theory was used as a framework to create a model to
educate nurses in the care of LPIs. The theory recognizes the significance of family
support, participation, and choice, and it is considered a fit for use in this context because
of the family-centered applicability. Nurses who are taught caring behaviors using
Swanson’s concepts will begin to communicate caring behaviors to patients and their
families. The nursing educational intervention is proposed to meet knowledge needs and
to improve outcomes for the LPI. Using Swanson’s caring model, content would focus on
teaching staff the unique physiology of the LPI, their needs in the neonatal period, and
ways of knowing and understanding the individual and family.
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Although the theory of caring has been applied to various populations, no
application to the late preterm infant (LPI) was identified in the literature. Little is known
about the nature of nurse caring that occurs in the LPI population, which may be due to
the fact that only recently has this population been identified as being at risk. Could
caring theory explain nurse caring in the LPI as it has in other populations? What effects
will the application of caring have on outcomes identified in the LPI population? Hanson
(2004) suggested that “recognizing factors that are likely to enhance the caring response
has potential to improve outcomes in nursing practice” (p. 22). Health care providers
have a primary focus of achieving optimum patient outcomes (Escobar et al., 2006).
Swanson (1991) has defined caring as fostering a relationship with a person with
whom one feels responsible and committed. According to Swanson (1993), the ultimate
goal of the nurse caring is the ability of the patient to achieve well-being. Swanson’s
caring theory uses five concepts to define caring. The concepts are knowing, being with,
doing for, enabling, and maintaining belief. In this theory, the concepts inform actions in
nursing that are seen as characteristics of caring relationships (Swanson & Wojnar,
2004). Swanson (1991) stated that these concepts are not mutually exclusive but are
overlapping processes with one central phenomenon of caring. In the application of the
caring theory to the proposed study, the five concepts are defined in the following
manner.
Knowing
Swanson (1991) described knowing as the striving to understand a person’s
experience from the perspective of the person living it. It involves centering, avoiding
assumptions, assessing thoroughly, seeking cues, and engaging self and the other
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(Swanson, 1991, 1993). Knowing, therefore, is based on the patient’s experience and not
the health care provider’s. Murphy (2009) viewed knowing as a multifaceted process and
challenged nurses to apply various techniques in relating to the patient. Kavanaugh,
Moro, Savage, and Mehendale (2006), in proposing a theory of caring to recruit and
retain vulnerable participants for sensitive research, asserted that in order to know the
participants, experts were used in the recruitment and retention process. The experts were
able to relate to the participants because of the knowledge and awareness of the
participants’ emotional and medical vulnerability. Murphy (2009), in her study of
facilitating attachment between mothers and their internationally adopted children, noted
that nurses’ knowing the adoptive mother and child’s specific needs was helpful in
responding to the mothers and their new additions. Carper (1978) described knowing as
the empirical, the science of nursing, acquired through nursing education.
In order to know the LPI, the nurse needs to assess the situation and view the
infant as a whole person, asking questions such as: Who is this infant? What do I need to
know about the infant’s history and condition? How can I help? What do I need to know
about the infant’s family in order to help them cope? The nurse avoids assumptions,
completes thorough assessments, and seeks cues while engaging parents as individualized
care is provided to each LPI and their family. The nurse focuses on what matters to the
infant and family members in the moment. The LPI education intervention that was given
to participants in this study will provide the nursery and post partum nurses with the
prerequisite needed to know LPIs and their families.
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Being With
Swanson (1991) described the next concept “being with” as authentic presence
with the other. It involves being emotionally present, conveying availability, sharing
feelings, and not burdening the person being cared for (Swanson 1993). It is more than
just “knowing” (Murphy, 2009). Caring is described as connecting knowledge to the
feeling to be in the moment with a group or an individual (Authier, 2004). Kavanaugh
(1997), in studying parents’ experience surrounding the death of a newborn at the margin
of viability, found that to the parents, “being there” meant that the nurse either was
physically present with the patient or could be reached easily when needed. Similarly,
Kavanaugh et al. (2006), in conducting qualitative research, found investigators are able
to “be with” study participants when they spend time sitting quietly with them and
offering them support. One who cares, is present as a person, is described as “one who
listens to their hearts, have love in their hands and warmth in their voice” (Karlsson &
von Post, 2010, p. 65).
In being with the infant, the nurse’s knowledge of the infant and family is
enhanced by the nurse being present emotionally. The nurse demonstrates a willingness
to become involved in the lives of the infants and family as feelings are shared. Mayeroff
(1971) stated that, in being present, one is able to participate with the other, in which one
fully gives of him/herself in the moment. The nurse spends time to start a relationship
with the LPI and family. Being present is essential to transforming a relationship
(Swanson, 1999a), which will be emphasized in the LPI education intervention of this
study.
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Doing For
Swanson (1991) described the next concept “doing for” as occurring when one
helps another person when they are unable to help themselves. It involves anticipating
needs, and skillful and competent performance of task that the patients are unable to
perform for themselves (Swanson, 1993). The actions illustrating this process include
comforting, protecting, preserving dignity, anticipating, and skillful performing of job
duties. According to Mayeroff (1971), “doing for” may include sitting quietly with the
patient and doing nothing, as nursing presence offers support.
The idea of doing for is that the nurse works toward completing assessments,
carrying out tasks, and providing learning opportunities to bring about a new or changed
condition in the infant and the environment, including the family of the infant (Banfield,
2011). The nurse anticipates infant and family needs and skillfully performs those tasks
in a caring way that promotes infant and family comfort level. The LPI education
intervention of this study will provide participants with the information needed to care for
LPIs and their families based on their unique needs.
Enabling
Swanson (1993) defined “enabling” as to the ability to assist others as they pass
through life events and transition to different facets of life. This is done by providing
information, validating concerns, and providing support. In enabling another, the nurse
uses her expert knowledge to the betterment of the other. The nurse learns to help the
patient think things through and come up with a solution (Swanson, 1991, 1993). The
actions that demonstrate this concept include providing information, explaining, allowing
support, and giving feedback (Swanson, 1991, 1993). Enabling has been used
14
synonymously with supporting, partnership, and empathy. In a study of community
health centers, enabling services such as interpreters and eligibility assistance were
utilized to improve access to health care among underserved patient populations of Asian
American, native Hawaiians, and other Pacific Islanders (Weir et al., 2010). In
Kavanaugh’s (1997) study of the parents’ experience of newborn death, staff “enabled”
family members by keeping them informed of treatment plans and the patient’s condition
in an easy and understandable language. Lindblad, Rasmussen, Sandman, and Holaday
(2005), in a study of children with disability, found that parents felt supported when they
learned to care for their disabled children confidently and competently. Therefore,
enabling includes sharing knowledge and teaching parenting skills.
In enabling parents, the nurse shares knowledge and teaches parenting skills,
providing the infant’s parents with information about their infant’s behavior and cues,
and prepares parents to perform caretaking tasks for their infants successfully. The nurse
understands that partnership will develop when parents begin to “read” their infant’s
behavior and adjust the care accordingly (Lindbald et al., 2005). It is anticipated that by
providing the LPI education intervention to nursery and post partum nurses, these nurses
not only will be able to provide appropriate care to these infants but also will be able to
inform family members on how to care for these infants at home.
Maintaining Belief
Swanson (1991) described “maintaining belief” as the belief in another person’s
capacity to find meaning in their experience regardless of the obstacles. The associated
actions include believing in, holding in esteem, and maintaining a hope-filled attitude
(Swanson, 1993). It is sustaining hope in the future. There is despair where there is no
15
hope (Mayeroff, 1971). Murphy (2009), in studying the international adoption process for
parents, described “maintaining belief” as having hope that offers encouragement for the
future and empowerment that leads to action in others. Powell-Cope (1994) described
“maintaining belief” as facilitating partnership because family members were able to
continue providing care to their loved ones with encouragement from the health care
providers. Family members perceived the nurse maintaining a positive attitude as caring
since it encouraged them to get through a difficult time (Powell-Cope, 1994).
The nurse sustains the parent’s faith in a positive outcome by informing them of
the infant’s progress as well as by validating and by generating alternative ways of doing
things. There is celebration for each milestone achieved and parental support for infant
failures. The nurse helps parents to bond with their infant. This study proposes that once
LPIs and their families are cared for by nurses who receive the LPI education
intervention using a caring lens, these families will have the appropriate infant care and
information, thus decreasing the number of hospital visits and readmissions of LPIs
within the first 30 days of life.
In summary, the theory of caring has been examined both from the perspective of
the caregiver (Hanson, 2004), family members (Kavanaugh, 1997; Powell-Cope, 1994),
and the patients being cared for (Finch, 2008; Watson, 2008). The different perspectives
between the caregivers and care-receivers have been identified, noting the behaviors that
patients deemed important in caring situations (Halldorsdottir, 1991). It is therefore
important for nurses to understand factors that affect their caring behaviors because
recognizing factors that enhance response to caring has a potential to improve patient
outcomes (Hanson, 2004).
16
Definition of Terms
The following definitions provide clarification for the study.
Dehydration is defined as less than four thoroughly wet diapers in a 24-hour
period and urine output less than 1ml/kg/hour (AAP, 2004).
Educational intervention was defined in this study as:
• Use of AWHONN’s “assessment and care of the late preterm infant”
posttest (20 items) (Appendix C). This is the LPI knowledge instrument
as a pretest measure of nurse baseline knowledge of the LPI
(AWHONN, 2010).
• Use of a modified version of Swanson’s Caring Professional Scale
(Appendix D). This is the LPI caring professional scale as a self
assessment of nurse caring behavior.
• Knowledge content outline, using Swanson’s caring theory in the
educational intervention, which includes the following.
The significance of the LPI: Overview, prevalence, and risk
factors and
Evidence-based practice guidelines: Gestational age
assessment, respiratory assessment, thermoregulation
issues, hypoglycemia, sepsis, jaundice, hypoglycemia,
feeding challenges, and parent teaching and support.
• Use of AWHONN’s “assessment and care of the LPI” posttest questions
as a measure of nurses posttest knowledge of the LPI (AWHONN, 2010)
17
• One month later, use of AWHONN’s “assessment and care of the LPI”
posttest questions as a measure of nurse retention of LPI knowledge
(AWHONN, 2010) and collection of health information management
data with regards to late preterm infant hospital visits or readmission for
hyperbilirubinemia and dehydration.
Gestational age is defined as number of weeks post menstruation that an infant is
born, based on estimated date of confinement and/or gestational age examination
(AAP/ACOG, 2012).
Hospital visits are defined as medical care for newborns after nursery discharge
occurring in the first 30 days of life in the primary care setting or in the hospital
emergency department (Jain & Cheng, 2006).
Hyperbilirubinemia is defined as an abnormally high total bilirubin blood level
specific value in mg/dl based on infants gestational age and hours post delivery compared
to Bhutani’s Total Serum Bilirubin Nomogram (Appendix E) (Bhutani et al., 2006).
These are the risk factors of developing severe hyperbilirubinemia.
Hypothermia is defined as axillary temperature below 97.7oF (36.5oC). Normal
axillary temperature ranges between 97.7o-99.3o F (36.5o-37.4oC) (AWHONN, 2010).
Knowledge is defined as the total score on the AWHONN (2010) “Assessment
and Care of the Late Preterm Infant: Evidence-based Clinical Practice Guideline”
posttest. Knowledge test questions address the associated risks and nursing management
of the late preterm infants and require 30 minutes to complete. The same test questions
were used at all three times (pretest, posttest 1, and posttest 2) and each item was scored
18
1 if correct and 0 if incorrect or missing. Possible scores can range from 0-100 percentage
points.
Late preterm infant is defined as an infant who is delivered at 34.0/7-36.6/7
weeks post conception (Raju et al., 2006). The infant is less mature than a full term infant
but more mature than an extremely premature infant.
Neonatal Hypoglycemia is defined as blood sugar level below 40 mg/dl.
However, there is no consensus as to the definition of neonatal hypoglycemia (Wang et
al., 2004).
Nursery nurse is a registered nurse who provides direct and indirect care to
healthy newborns. Respiratory distress is defined as sustained distress more than two
hours after birth, accompanied by grunting, flaring, tachypnea, retractions, or
supplemental oxygen requirement (Wang et al., 2004).
Post partum nurse is a registered or licensed nurse who provides direct or indirect
care to mothers and their healthy newborns (as a couplet).Readmission is defined as an
infant who is readmitted after discharge from the birth hospital for high bilirubin levels
and/or dehydration in the first 30 days of life (Jain & Cheng, 2006).
Assumptions
The following assumptions have been made for this study:
• Nursery and post partum nurses lack knowledge on how to appropriately care
for LPIs and their families.
• The questionnaire will accurately assess the participants’ knowledge of the
LPI.
19
• Participants will complete pre and post LPI knowledge tests and self
assessment of caring.
• Participants will attend the entire LPI education intervention.
• Participants who have completed the educational intervention will use a
holistic approach to care for LPIs and their families.
• The families of LPIs cared for by nurses who have completed the LPI
education intervention will have a better understanding of how to take care of
their infants at home.
• All LPIs delivered at the study location will return for hospital visits and
readmission to a hospital within the health care system, thereby allowing for
accurate data collection.
Summary
The LPI is “described as unrecognized, underestimated, unpredictable and
understudied” (Jorgensen, 2008b, p. 327). Risk factors associated with this group were
discussed with short-term outcomes of increased length of hospital stay and
rehospitalization in the first 30 days of life (Raju et al., 2006). Several studies have
indicated that more long term effects on health exist in LPIs than in full term infants. The
need to educate health care providers, particularly nurses, has been identified. The
purpose of the study was to use a pre and posttest study design to examine the
effectiveness of a late preterm infant educational intervention on the knowledge among
nursery and post partum nurses using Swanson’s (1991) caring theory, and to explore
implementation outcomes for hyperbilirubinemia and dehydration in this population of
infants. It was hypothesized that there will be a difference between the pre and posttest
20
knowledge score and reduced outcome for readmission and hospital visits rate for
hyperbilirubinemia and dehydration at one month later.
21
CHAPTER TWO
LITERATURE REVIEW
The primary purpose of this review of the literature is to examine the empirical
and literary work of researchers who have conducted studies or reviewed research related
to the proposed study areas of interest. This chapter is composed of three sections. The
first section addresses the caring theory. The second section addresses the identified risks
associated with the LPI with a review of the relevant research studies. Of particular
interest are infants delivered between 34-36.6 weeks gestational age. The third section
addresses investigations on the impact of educational intervention as it influences
practice environments and outcomes. An attempt is made to incorporate studies
addressing caring theory since the current proposed study intends to use an educational
intervention incorporating Swanson caring theory to familiarize nurses on appropriately
and confidently caring for LPIs and their families. A literature search was conducted
from 2004 to 2012 using CINAHL and MEDLINE databases with the search words
“theory of caring,” educational intervention, “near term,” and “late preterm infant.”
Theory of Human Caring
“Caring” is an integral aspect of nursing. Caring is “the hallmark of effective
nursing practice and a desirable characteristic of all nurses” (Finch, 2008, p. 25).
According to Leininger (1994), caring is the unique and unifying focus of the nursing
profession. Watson’s (2008) theory of caring centers on the transpersonal aspect of caring
in human relationships. Watson referred to her caring processes as caritas nursing, which
22
she described as bringing caring, love, and heart-centered human practices to one’s
personal and work life. In the past decade, theory-guided practice models and caring and
healing relationships have been recognized as a core of professional nursing (Watson,
2002). This shift, according to Watson, is due to an awareness of the lack of caring in
human interaction with each other. Health care settings now are practicing massage
therapy, therapeutic touch, aromatherapy, and music therapy as alternative ways of
providing a calm healing environment for the nurse and the nursed (Watson & Foster,
2003).
Several grand theories of caring have emerged in nursing over the last two
decades with eminent theorists such as Leininger (1994), Roach (1984), Watson (1979,
1985), and Boykin and Schoenhofer (1990). Despite the different perspectives, each
theorist has emphasized the importance of authentic presence and interconnectedness
(Boykin & Schoenhofer, 1990). Swanson (1991, 1993) posited that lack of caring in
nursing has had a negative outcome for both the nurse and the patient. She thereafter
introduced a phenomenological derived middle range theory of caring that embraces five
overlapping concepts.
In developing a middle range theory of caring, Swanson was influenced both by
theorist Jean Watson (Swanson, 1993) and by interacting with patients and their families.
Swanson (1991) defined nursing as the “informed caring of the well being of others” (p.
352); she saw caring as “a nurturing way of relating to a valued other towards whom one
feels a personal sense of commitment and responsibility” (p. 162). Swanson (1991)
proposed a caring theory that embraces five caring concepts, each with multiple
subcategories as the major tenants of her theory. The concepts emerged from her three
23
studies of caring. The first study (Swanson-Kaufman, 1986) focused on caring as
experienced by women who miscarried (n=20). The question that guided the study
focused on what caring behaviors the women found helpful during the period of
miscarriage. In the second study, Swanson (1990) examined the experience of being
caregivers, parents, and health care providers in the newborn intensive care unit (NICU)
(n=19). The third study (Swanson, 1999b) explored the perception of the nurse-patient
relationship in at risk mothers who completed four years of participating in a public
health nursing intervention program (n=8). The concepts that emerged from these studies
were knowing, being with, doing for, enabling, and maintaining belief, which were
developed from her analysis of these research studies (Swanson, 1991, 1993).
The concept of caring has been studied for over two decades (Andershed &
Olsson, 2009; Finch, 2008; Hanson, 2004; Kavanaugh, 1997; Powell-Cope, 1994; Smith,
2004). Although the theory of human caring has been used in studies of various
populations, no studies related to the late preterm infant (LPI) were identified in the
literature. As a result, little is known about the nature of nurse caring on LPI outcomes.
Blum, Hickman, Parcells, and Locsin (2010) posited that, although the importance
of caring behaviors on patient outcomes have been delineated, few studies have been
conducted on teaching caring behaviors to nurses. Using a pretest/posttest study design
within a caring framework, the authors compared the influence of teaching caring nursing
on the caring behaviors of RN-BSN students in a 15-week health assessment course using
simulation technology. They examined the effect of this new model in teaching caring
and concluded that “caring nursing can be modeled and taught in nursing education using
simulation technology” (Blum et al., 2010, p. 48). However, few studies were identified
24
using a pretest posttest design to evaluate the effectiveness of a caring theory to change
nursing behavior.
Glembocki and Dunn (2010) used a pretest/posttest within subject research design
to determine if an education intervention called Reigniting the Spirit of Caring (RSC)
from Creative Healthcare Management would enhance the perception of caring behaviors
among nurses. The authors used the Care Assessment of Caregiver (CAC) instrument as a
pretest/posttest and the RSC program as the intervention in a 3-day seminar with 36
registered nurse attendees. The CAC instrument is a 25-item evaluation tool that is
divided into groups of five items that correlate with Swanson’s five caring concepts. The
authors concluded that though the seminar assisted nurses with reflecting on self and
caring behaviors, there was no evidence that there was an improvement in the nurses’
caring behaviors.
Swanson (1999b) conducted a meta-analysis of 130 studies on caring and detected
the positive and negative outcomes of caring and non-caring behaviors of the nurse in
nursing situations. Positive outcomes like emotional and spiritual wellbeing, increase in
trusting relationships, and family support were noted when patients experienced caring
behaviors from the health care provider. Conversely, humiliation, fear, and decreased
healing were felt when patients experienced non-caring behaviors from the health care
provider. In the same studies, nurses were positively affected when they practiced caring
behaviors and negatively affected when they practiced non-caring behaviors. Swanson
concluded that caring behaviors positively affect both the nurse and the nursed.
In summary, there is an identified need to improve nursing education for the
management of the LPI. The skill and experience of the nursing staff influence the
25
decisions made in caring for the LPI. Well-informed nurses should be involved in
partnering with parents and caregivers on the care of the LPI. Using caring theory to
uncover the needs of LPI and families, incorporating a holistic approach, and creating a
teaching-learning intervention will provide nurses with a framework for seeing each LPI
as unique, with special requirements for the assessment and management of their
individual needs. It is hoped that the use of the caring theory to develop an LPI education
intervention will extend to families of LPIs so that they are able to understand the needs
of their infant as different from a full term infant.
Risk Associated with the Late Preterm Infants
A review of the literature revealed several significant findings related to the LPI.
A broad range of neonatal complications has been identified in the growing, but small,
body of literature on the LPI. These complications include respiratory distress syndrome,
temperature instability, prolonged physiologic jaundice, hypoglycemia, feeding
difficulty, infection, developmental delays, and parenting stressors (Escobar et al., 2006).
The infant morbidity and mortality rate is three to four times higher in the LPI than their
full term counterpart (Adamkin, 2009; Darcy, 2009; Engle et al., 2007), with a 12-fold
higher risk of death and with an overall mortality rate of 0.8% (Mohajan, Rahman,
Seidhtz, Wilson, & Paes, 2009). The recommendation is that these infants will require
frequent follow-up visits with a health care provider in order to avoid hospital
readmission with feeding and growth issues (Jain & Cheng, 2006; Mally et al., 2010).
Though healthier than a premature infant, the LPI may not be as healthy as full term
infants. LPIs are likely to be readmitted for inadequate glucose and bilirubin metabolism,
regulation of breathing, temperature control, awake/alert behavior states, and ineffective
26
feeding (Bhutani & Johnson, 2006; Hillman, 2007; Medoff-Cooper et al., 2005; Meier et
al., 2007).
Morbidity and Mortality
Shapiro-Mendoza et al.(2006) conducted a population based study on 9,522 LPIs
(from 1998-2002) and found that mothers who had any reported labor and delivery
complications or who had a public payer source at delivery had an associated increased
neonatal morbidity. Of the 577 readmission and observational stays, 63% of LPIs were
diagnosed with jaundice occurring in the first three to five days of life. On further
differentiation of the findings, breast-fed late preterm infants were at increased risk for
readmission for jaundice, poor weight gain, and feeding difficulties. The authors
concluded that the findings could help HCPs to identify mothers who need additional
breast-feeding instruction before discharge, and earlier follow up care post discharge.
Tomashek et al. (2006), in a population based retrospective study of 1,004 late
preterm and 24,320 term infants born between January 1, 1998 and November 30, 2002,
compared the risk of neonatal morbidity between late preterm and term newborns
discharged home early (<2 night hospital stay) following a vaginal birth. The authors
noted that exclusively breast-fed LPIs whose mothers were mostly teenagers from
minority groups with no college education were one and one half times more likely to
require hospital related care and nearly twice as likely to be readmitted for dehydration
from inadequate feeding and jaundice within the first 28 days of life. The authors
therefore suggested that an evidence-based discharge guideline was needed to prevent
neonatal morbidity.
27
In another study by Tomashek et al. (2007), a comparison was made from 1995 to
2002 of trends and differences in mortality by age at time of death between late preterm
and term infants. Late preterm infants also were four times more likely to die from
congenital abnormalities; newborn sepsis; and complications of placenta, cord, and
membrane. The authors concluded that LPIs have higher mortality rates than term infants
during infancy and suggested that the study findings may be used as a guide in obstetrical
practice.
Escobar et al. (2006) reviewed existing published data from England and the
United States from 1998 to 2004. Their goal was to quantify short term hospital outcomes
for late preterm infants born between 35-36 weeks postmenstrual age. Findings included
increased mortality and morbidity in this age group as compared to term infants. These
LPIs were much more likely to be re-hospitalized and three times more likely to require
respiratory support than their full term counterparts. The authors suggest greater attention
be paid to the management of this group of newborns, with emphasis on evaluating the
therapies and follow up strategies used in caring for the LPI.
In a retrospective review of 185 medical records from 1997 to 2000 conducted by
Wang et al. (2004), the researchers explored whether late preterm infants had more
medical problems and longer hospital stay/costs than their term counterpart. Though
median length of stay was about the same for both groups, clinical outcomes were
significantly different. LPI were “twice as likely to have several clinical problems
resulting in the assignment of two or more diagnosis (50% vs 21.1%; OR: 3.72; 95% CI:
1.88-7.55; p=.0001, FE)” (p. 373). The late preterm infants had significantly higher costs
with a mean cost difference of $429 per term infant compared to $2,630 per late preterm
28
infants (p=.0004). The authors concluded that the late preterm infants have more medical
problems with increased hospital costs than their term counterparts and suggested further
exploration of their findings.
Young et al. (2007) reviewed data from birth and death certificates of LPI born in
Utah from 1999-2000. The goal was to determine the risk for mortality and the
causes/ages at death. Causes of death for terms and LPIs were grouped into eight
categories with birth defect being the most common cause. Mortality rate remained
significantly higher in the LPIs than the term infants after excluding birth defect as a
reason for death. The authors believe that the findings provided evidence for further
research and management guidelines in the care of the LPI.
Shapiro-Mendoza et al.(2008) conducted a population based retrospective study.
The goal was to compare term and late preterm infants with and without selected
maternal medical conditions and the effect on newborn morbidity risks. These researchers
found that LPIs are seven times more likely to have newborn morbidity risks than their
term counterparts. Morbidity rate doubled for each gestational week earlier than 38
weeks. LPIs, especially those exposed to antepartum hemorrhage and high blood
pressure, were at higher risk of newborn morbidity than their term counterparts. The
researchers concluded that LPIs and maternal medical condition combined greatly
increased morbidity for the LPI.
In an 18-year retrospective study, McIntyre and Leveno (2008) performed an
analysis to compare morbidity and mortality of late preterm infants (34-36 weeks) with
term infants and to estimate the magnitude of increased risk associated with both groups
immediately after birth. Findings of the study suggested that the newborn morbidity was
29
significantly higher (p=.05) in the preterm group and that preterm labor was the most
common reason for late preterm births. According to the researchers, preventing preterm
labor has not been successful in the United States. The researchers therefore concluded
that until there are new developments in the prevention and management of preterm
labor, the problem with LPIs will remain.
These studies clearly indicate the issues and concerns associated with the LPI.
Therefore it is imperative that further interventions are developed to ensure caregivers are
educated properly during their infant’s hospital stay as well as following their infant’s
discharge from the hospital.
Hyperbilirubinemia (Jaundice)
Neonatal jaundice is a benign, self-limiting, non-problematic condition that is a
common occurrence in at least 60% of newborns in the first few days of life (AWHONN,
2006). Hyperbilirubinemia is an abnormally high concentration (given the age of the
infant in hours) of the serum bile pigment bilirubin (AWHONN, 2006). It is the most
common clinical condition requiring evaluation and treatment in the newborn (Escobar et
al., 2005) and has been identified as one of the most common reason for LPI readmission
(Bhutani et al., 2006; Hillman, 2007; Meier et al., 2007; Pados, 2007; Shapiro-Mendoza
et al., 2008; Shapiro-Mendoza et al., 2006). Factors that impair an LPI’s ability to
appropriately manage bilirubin levels include the infant’s physiological immaturity and
dehydration due to poor breast-feeding (Bhutani & Johnson, 2006; Smith, Donze, &
Schuller, 2007). The LPI is at risk for bilirubin neurotoxicity and severe
hyperbilirubinemia (AAP, 2004) because of low albumin levels and immature liver
function with less ability to metabolize bilirubin (Bhutani & Johnson, 2006), which then
30
peaks to high levels at five to seven days of life. This is complicated further by the
presence of infection, hypoglycemia, and hypothermia. Approximately 25% of LPIs will
require phototherapy to treat high levels of bilirubin (Pados, 2007). If not well managed,
high bilirubin levels can lead to the development of Kernicterus or bilirubin
encephalopathy (Bhutani & Johnson, 2006; Pados, 2007; Smith et al., 2007), which can
increase the morbidity and mortality rates in these infants.
A retrospective study conducted by Bhutani and Johnson (2006) compared the
clinical profile and health experiences related to the management of newborn jaundice
and hyperbilirubinemia in LPIs managed as term infants who developed acute/chronic
posticteric sequalae. The sample included LPIs and term infants (N= 125) who were
reported into the Kernicterus registry. Post icteric consequences were more severe and
frequent in the LPI and health care providers did not recognize that being an LPI was a
risk factor for increased bilirubin level. Poor breast-feeding was a major contributing
factor and increased bilirubin levels were not identified by health care providers either
before discharge or at follow-up. A knowledge deficit was identified and an intervention
was required to improve practice and thereby outcomes for this population.
Harris, Bernbaum, Polin, Zimmerman, and Polin (2001) reviewed medical records
from 1993-1996 of 36 weeks or greater post conceptual age (PCA) infants readmitted in
the first week of life with bilirubin level of >25mg/dl. The purpose was to evaluate for
early or late evidence of bilirubin brain injury. Six infants who met the inclusion criteria
had been discharged within 48 hour after birth and had bilirubin levels >30mg/dl. All of
the infants either were exclusively breast-fed or fed a combination of breast milk and
formula. Five of the six infants had transient neurological deficits that resolved with
31
aggressive management (hydration, phototherapy, and exchange blood transfusion). The
researchers speculated that early discharge in conjunction with inadequate breast-feeding
may have contributed to increased bilirubin levels. They called for further studies to
investigate the frequency of this finding.
Keren et al. (2008) conducted a prospective comparative cohort study of 823 term
and late preterm infants. The comparison was on alternate assessment methods for the
risk of increased hyperbilirubinemia. The researchers compared three bilirubin
assessment strategies. Findings suggested that the most accurate risk assessment
strategies are infant gestational age and level of pre-discharge bilirubin levels. The
authors therefore concluded that an infant’s risk of developing a high bilirubin levels can
be assessed by a combination of the predischarged bilirubin level (expressed as a risk
zone on an hour specific bilirubin nomogram) and the infant’s gestational age.
Sarici et al. (2004) performed a comparison retrospective study of 365 term and
preterm infants to investigate the incidence of hyperbilirubinemia in the first seven days
of life. The purpose of the study was to determine if early serum bilirubin measurements
predict the development of increased bilirubin in the first week of life for the late preterm
infant. The researchers found significant differences in the level of increased bilirubin
between the two groups, 10.5% in term compared to 25.3% in the LPI. The
recommendation for practice was that LPIs should not be treated with the same bilirubin
management guidelines as for term infants. The authors concluded that nomograms can
be used to predict the risk of hyperbilirubinemia.
Bhutani et al. (2006) conducted an observational study to examine the health
outcomes related to an institutional systems approach on the management of neonatal
32
hyperbilirubinemia. The purpose was to manage newborns jaundice for safer outcomes.
A system-based approach was used that included current practices requiring bilirubin
levels to be monitored at 48 hours of age prior to discharge. The population was 31,069
live birth infants discharged as healthy term as well as late preterm newborns. Findings
indicated that with a progressive implementation of a system based approach, there was a
steady and significant decrease in occurrence of adverse events caused by newborn
jaundice. Intervention included a policy that allowed nurses to obtain bilirubin levels at
time of metabolic screening (at 48 hours of age) and appropriate follow up using the
nomogram. The adverse outcomes for newborns with exchange blood transfusions,
intensive phototherapy treatment, and readmission were reduced. The study supported
current hospital policies that encourage nurses to independently assess (i.e., without a
doctor’s order) infant bilirubin levels before discharge.
In summary, the LPI is vulnerable to developing brain damage due to high
bilirubin levels (Mally et al., 2010). It is important to have clear guidelines on the
management and treatment of hyperbilirubinemia to prevent adverse outcomes.
Preventive measures include nursing and parental education, nurses screening infants for
jaundice before discharge, and nurses providing lactation support. Nurses are able to
educate parents on watching for cues for increasing jaundice following early discharge,
stressing the importance of early follow-up with community health care providers.
Respiratory Distress
Respiratory distress has been defined as sustained distress more than two hours
after birth accompanied by grunting, flaring, tachypnea, retractions, or supplemental
oxygen requirement (Wang et al., 2004). Most research in the past was aimed at the very
33
low birth weight infant (VLBW), with comparatively little research conducted on the
more mature infants such as LPIs and term infants. In recent years, findings from several
studies have suggested that LPIs are at higher risk for respiratory distress including
transient tachypnea of newborn (TTN), respiratory failure, respiratory distress syndrome
(RDS), and persistent pulmonary hypertension of newborn (PPHN) than their term
counterpart (Engle et al., 2007; Jain & Chen, 2006; Wang et al., 2004). One of the major
drivers for increased morbidity and mortality is the presence of various forms of
respiratory distress. Most common respiratory issues are respiratory distress syndrome
(RDS), pneumonia, and a variety of not well-defined conditions that are placed under the
category of TTN (Escobar et al., 2006). LPIs have a higher risk of poor outcomes during
birth hospitalization, including a need for mechanical ventilation (Mac Bird et al., 2010)
and an increased length of stay (Ramachandrappa & Jain, 2009). Contributing factors to
an LPI’s respiratory distress are deficiency of surfactant (due to prematurity) and
decreased clearance of lung fluid (due to surgical birth). LPIs are nine times more likely
to have respiratory distress than the term infant (Wang et al., 2004). Due to the absence
of normal hormonal and mechanical changes that occur in vaginal births, infants
delivered by cesarean section (C/S) are five times more likely to have respiratory distress
than those by vaginal birth (Hansen, Wisborg, Uldbjerg, & Henriken, 2008). The LPI
with respiratory distress needs further evaluation for sepsis as infants born before 37
weeks account for 72% of fatal cases of sepsis (Gessner, Castrodale, & Soriano-Gabarro,
2005).
Roth-Kleiner et al. (2003) conducted a 3-year study to document the severity and
frequency of hyaline membrane disease (HMD) in LPIs delivered by C/S. The findings
34
suggested a decrease in RDS from 36-40 weeks post conceptual age (PCA). The
researchers noted that the performance of a C/S in the absence of labor increases the risk
of RDS. The authors concluded that the severity of illness in elective C/S (in the 36-40
weeks PCA group) may be high and are comparable to the severity of illness in infants
delivered by C/S who were <36 weeks PCA. The authors also concluded that health care
practitioners need a change in practice when performing early elective C/S, with
consideration given for medical reasons.
Merchant, Worwa, Porter, Coleman, and deRegnier (2001) conducted a study of
term and late preterm healthy infants to evaluate respiratory stability and safety
requirements in car seats. Apnea and bradycardia was diagnosed in 12% of the LPIs
while term infants had none. The result supports the current AAP/ACOG (2012)
recommendation that all infants less than 37 weeks gestational age be observed for
respiratory concerns while in a car seat prior to discharge. Parents therefore are
encouraged to use a car seat for traveling but to minimize travel time in the first few
months of an infant’s life.
In a retrospective electronic medical record (EMR) review, the Consortium on
Safe Labor (2010) evaluated data from LPIs (n=19,334) and term infants (n=165,993)
delivered between 2002 and 2008. The incidence of respiratory distress was more
prevalent for infants born at 34 weeks gestation compared to those born at 38 weeks or
higher. The authors noted that the odds of respiratory distress were reduced with each
additional gestational week. At 37 weeks, chances of respiratory distress were higher than
at 39-40 weeks (adjusted OR, 3.1; 95% CI, 2.5-3.7), though there was no difference at 38
weeks than at 39-40 weeks. The authors therefore concluded that there was an association
35
between late preterm birth and an increased risk of respiratory distress. In summary, there
is a high incidence of further complications associated with respiratory distress in the
LPI.
Hypothermia and Hypoglycemia
Although all newborns are at risk of heat loss at birth due to radiation, conduction,
convection, and evaporation, the LPI is at greater risk than the term infant because of an
immature epidermal barrier, underdeveloped glycogen stores, a higher surface to body
mass ratio, and decreased subcutaneous and brown fat (AWHONN, 2010). The LPI body
temperature should be maintained between 36.5-37.5 degrees centigrade (Darcy, 2009).
An infant who is hypothermic is at risk for hypoglycemia and respiratory distress
(AWHONN, 2010). Wang et al. (2004) identified that 10% of LPIs with hypothermia
require an active intervention. As an LPI uses calories to generate heat, they may have
less energy for feeding (Cleaveland, 2010).
Neonatal hypoglycemia (NH) is not in itself a medical condition but can be an
indication of underlying illness or failure to adapt physiologically to the outside after
birth (Joanna Briggs Institute, 2007). The newborn must become self sufficient in the
manufacturing of glucose when the maternal supply is cut off at time of delivery. There is
no consensus as to the definition of NH, who is at risk, or the level and duration of NH
that may cause neurologic insult (Adamkin, 2009). Though it has been recognized in the
literature that there are detrimental effects of low circulating glucose concentrations, the
actual level at which effects occur remain unknown, contributing to the difficulty of
making a clinically useful definition (Garg & Devaskar, 2006). In 2008, an expert panel
convened by the National Institute of Health (NIH) concluded that since there was no
36
evidence-based definition of NH, management should include monitoring, prevention,
and treatment in order to prevent complications related to hypoglycemia (Committee on
Fetus and Newborn, 2011). Early identification of at risk infants and the institution of a
practical approach that includes adopting an operational threshold for NH are the key
(Noerr, 2001). The LPI is at high risk for hypoglycemia due to their reduced ability to
produce glucose, the presence of an immature glucose-regulated insulin secretion, and
decreased glycogen and fat stores (Souto, Pudel, & Hallas, 2010).
Recent clinical investigations have suggested that blood sugar levels of less than
40mg/dl warrant a diagnosis of hypoglycemia. The association of hypoglycemia with
neurodevelopmental abnormalities has prompted increased recognition, anticipation,
diagnosis, and therapy of neonatal hypoglycemia (Rozance & Hay, 2006). Seizure,
respiratory depression, irritability, hypotonia, apnea, inactivity, high pitch cry, and poor
feeding may be seen in severe hypoglycemia, and symptomatic hypoglycemia increases
the risk of central nervous dysfunction with associated neurologic sequelae (Vannucci &
Vannucci, 2001). The compensatory mechanism that protects the LPI’s brain from
hypoglycemic insults is not yet in place, which could affect the neurodevelopmental
outcome for these infants (Garg & Devaskar, 2006).
The risk of hypoglycemia increases further when energy demands increase
because of coexisting conditions of sepsis, birth asphyxia, and cold stress; there also are
further complications because low blood glucose levels are associated with increased
cerebral flow (Jain et al., 2010). Additionally, small feedings associated with the LPI
gastrointestinal immaturity and poor suck-swallow and breath coordination contribute to
the LPI’s risk for hypoglycemia (Laptook & Jackson, 2006). Moreover, the LPI is three
37
times more likely to be hypoglycemic than the term infant, which may be due to a delay
in the LPI glucose-6-phosphatase activity (Mally et al., 2010). Though study findings of
symptomatic and asymptomatic hypoglycemia in term and preterm infants have shown
differing degrees of neurological sequelae, similar studies do not exist specifically for the
LPI. “Most of the investigations related to hypoglycemia undertaken so far have involved
all infants with mixed diagnosis” (Garg & Devaskar, 2006, p. 867).
In summary, an infant’s ability to maintain their temperature and blood glucose
level will determine a successful transition in the first few hours of life (Mally et al.,
2010). Temperature instability can lead to hypoglycemia and vice versa. The
recommendation is for an hourly monitoring of blood glucose levels for the first three
hours of life with the expectation that the levels would have stabilized (Souto et al.,
2010). For proper management of the LPI irrespective of place or mode of delivery, body
temperature and glucose measurements must be monitored repeatedly. The
recommendation that has been proposed and adopted includes monitoring of temperature
to prevent hypothermia since cold stress can lead to and worsen hypoglycemia in the LPI
(Laptook & Jackson, 2006). A fundamental function of caring for newborns is the
recognition of neonates at risk for hypoglycemia and hypothermia.
Feeding Challenges
Much of the literature is focused on the nutritional needs of the very low birth
weight (VLBW) infant without addressing the needs of the LPI. LPIs have suck-swallow
coordination problems related to their immature reflexes and decreased oromotor tone,
which may lead to inadequate intake for the bottle feeding infant and poor latch for the
breast-feeding infant (AWHONN, 2006). Sucking, swallowing, and breathing must be
38
well coordinated in order to achieve safe and efficient oral feeding (Ludwig, 2007).
Triaging the LPI poses more problems than the term infant. Additionally, the LPI may be
sleepier and exhibit less stamina due to immaturity (Adamkin, 2009); there also is a
tendency to sleep through feeds, which may result in inadequate fluid intake. Review of
issues associated with the LPI show that feeding challenges place this vulnerable
population of infants at risk for prolonged hospital stays and readmission after discharge.
Raju et al. (2006) and Escobar et al. (2005) found that the second most frequent
reason for rehospitalization of the LPI is feeding difficulties at 32% and 26%
respectively. The disheartening trend is that despite documented benefits of breast milk,
breast-fed LPIs are readmitted to the hospital more frequently due to dehydration,
jaundice, infection, and failure to thrive (Wang et al., 2004). While the LPI may show
signs of “poor feeding” while in the hospital, they may be able to get by until after
discharge at which time they are unable to cope with the higher volume of feeds needed
for growth.
Medoff-Cooper and McGrath (2000) reported that there are differences in feeding
patterns between the LPI and their full term counterpart, although, historically, the LPI is
expected to feed as well as the term infant. The differences in muscle tone, state
regulation, endurance, and suck-swallow-breath coordination affect the LPI’s transition
to full feeds. While one 35-week PCA may feed efficiently and be discharged home
without feeding issues, another 35-week PCA with commodities may exhibit difficulty
transitioning to full oral feeds (Ludwig, 2007). It therefore is important that care is
individualized to meet each LPI’s specific need.
39
In summary, though born only a few weeks early, the LPI has feeding problems.
Incorporating a team approach with the various disciplines (occupational and speech
therapist, lactation consultant, and physician) will alleviate some of these problems
(Mally et al., 2010). The AAP/ACOG (2012) recommends frequent breast-feeding (8-10
times in a 24-hour period) and lactation support, which has been shown to reduce high
bilirubin levels in exclusively breast-fed LPIs. Additionally, timely evaluation following
discharge is important because the feeding issue may become more apparent between
time of discharge and the first office visit.
Neurodevelopmental Issues
The LPI brain at 34 weeks of gestation weighs 65%, with an additional 35%
increase required to reach term weight (Huppi et al., 1998). “There is a critical period of
brain development that occurs in late gestation that is vital to the development of various
neural structures and pathways” (Mally et al., 2010, p. 228). More than one third of the
brain volume is acquired in the last six to eight weeks of pregnancy and the white matter
volume increases fivefold (Kinney, 2006). Therefore, the timing of birth leaves the LPI
less prepared to respond to stimuli and the LPI may be more prone to brain injuries with
neurodevelopmental problems (Petrini et al., 2009; Raju et al., 2006; Ramachandrappa &
Jain, 2009). Several studies have indicated that more long-term effects on health exist in
LPIs than the full term infants. A higher incidence of cerebral palsy (CP), mental
retardation (MR), behavioral, and emotional disturbances was identified in a large LPI
cohort study done in Norway by Moster, Lie, and Markestad (2008). In a similar study in
Northern California, Petrini et al. (2009) noted that being born premature is associated
with CP, MR, and developmental delays (DD). Late preterm infants were more than three
40
times as likely to have CP than their term counterparts (hazard ratio 3.39, 95% CI, 2.54-
4.54) and a modest association (hazard ratio 1.25: 95% CI, 1.01-1.54) was noted for
DD/MR than for their term counterparts.
In another study to analyze the effect of being preterm on disability and
vocational success of adults in their twenties, Lindstrom et al. (2007) found that those
born between 33-36 weeks gestational age were more likely to receive disability and less
likely to attain higher education. Similarly, McGowan, Alderdice, Holmes, and Johnson
(2011) and Morse, Zheng, Tang, and Roth (2009) suggested that LPIs are at increased
risk of early childhood developmental delays and academic difficulties.
Chyi, Lee, Hintz, Gould, and Sutcliffe (2008) used test scores, teacher evaluation,
and special education enrollment to compare school outcomes for moderate preterm (32-
33 weeks gestation), late preterm (34-36 weeks gestation), and term infants. The authors
concluded that there was a constant teacher concern through the fifth grade and greater
special education needs among moderate and late preterm infants than their term
counterparts.
Medoff-Cooper and McGrath (2000) studied 66 preterm infant delivered at 24-34
weeks PCA. The study addressed the issue of developmental delay in LPIs compared to
term infants. The infants were 34-40 weeks PCA at the time of the study. The purpose of
the study was to investigate the changes that occur in nutritive sucking patterns,
behavioral state, and neurobehavioral development of the preterm infants from age 34
PCA until term. There were significant difference in number of sucks (p<0.001), the
intensity of sucking pressure (p<0.001), average time between sucks (p<0.001), and
average time between bursts (p<0.001) from 34 weeks PCA to term. The infants also
41
were more alert during sucking from 34 weeks until they reached term. The suggestion is
that preterm infants suck better after 34 weeks and still are able to stay more alert from
34 weeks PCA to term. Therefore, nurses can assess an infant’s behavioral state to
identify when to begin to offer oral feeds. The relatively large size of the LPI places them
at risk for feeding issues, including breast feeding with dehydration and feeding
difficulties, which ultimately delay discharge from the birth hospital.
Considerable evidence and expert opinion have suggested that the morbidities
associated with LPI are prevalent and the rates are higher when compared with the full
term counterparts. Understanding morbidity risk among LPIs will assist health care
providers in anticipating and managing potential problems associated with this group. “A
comprehensive understanding of these issues by physicians, nurses, and hospital
administrators is essential to determine the resources necessary to care for a cohort of
infant in whom the risks of medical problems are often overlooked” (Laptook & Jackson,
2006, p. 26). Nurses caring for these infants need a different perspective, familiarizing
themselves of the risk factors associated with this group of infants in order to tailor their
care appropriately and differently than the infants’ term counterparts (Shaw, 2008).
AWHONN (2010) developed evidence-based clinical practice guidelines from four
concepts that describe the needs of this population of infants in order to achieve healthy
outcomes: physiologic functional status, nursing care practices, care environment, and
family role. The “Late Preterm Infant Assessment Guide” developed by AWHONN
(2010) guides nurses in the development of protocols that provide assessment,
intervention, and parenting education guides that are evidence-based in the areas of
respiratory distress, thermoregulation, jaundice, and feeding problems (Askin, Bakewell-
42
Sachs, Medoff- Cooper, Rosenberg, & Santa-Donato, 2007). The proposed study will use
an LPI education intervention developed based on AWHONN’s (2010) evidence-based
clinical guidelines and protocols using the framework of Swanson’s (1991) theory of
caring to increase the LPI knowledge and nursing care comfort levels among nursery and
post partum nurses.
Educational Intervention
There is an identified need to improve nursing education for the management of
the LPI as the skill and experience of the nursing staff influence the decisions made in
caring for the LPI. Health care providers’ knowledge deficit has been related to the belief
that the LPI will behave like a term infant due to their physical appearance and size.
Increasing the LPI knowledge and nursing care comfort levels of the nursery and post
partum nurses should be a primary focus (Medoff-Cooper et al., 2005). Well-informed
nurses should be involved in partnering with parents on care of the LPI to improve health
care outcomes for these infants. Appropriate education also is needed to dispel the myth
that the LPI is “just another newborn” (McGrath, 2007, p. 121). A major goal in
providing staff education is to reduce the number of potentially preventable problems for
the LPI. The premise is that if an informed nurse educates parents on the care of the LPI
during hospital stay, the parents will continue the same quality of care after the LPI is
discharged. It also is anticipated that the proposed LPI education intervention used in this
study will improve nurse confidence in providing care, reduce the number of infant
readmissions, and ultimately reduce the associated health care costs.
Despite the identified need to educate health care providers on the care of the LPI
to decrease morbidity and mortality rates among these infants, there still remains a lack
43
of empirical studies in the literature regarding LPI education intervention for health care
providers in general and nursing in particular. However, it may be judicious to review
and critique other education interventional studies done among nurses and other health
care providers to support the method that this proposed study will use to educate nurses
on LPIs and increase their comfort level when caring for these infants.
Semelsberger (2009) conducted a review of 10 studies that have used an
educational intervention to reduce catheter-related blood stream infection (CRBSI) in the
NICU. The educational intervention methods used included lectures, self study, in-
services, and pretest and posttests. The author postulated that although not all studies had
significant differences in the outcomes, all had some improvement and change in nursing
practice, regardless of what education interventional method was used.
In another study conducted by Pineda, Foss, Richards, and Pane (2009), the
authors used a pretest and posttest comparison study to evaluate a change in breast-
feeding practice after a nursing education intervention. The participants included health
care providers in a NICU (n=88). Infants who were admitted six months before the study
were compared to infants admitted after the educational intervention. During a 6-week
period, the daily breast-feeding rate, breast milk feeding initiation rate, and breast milk
feeding at time of discharge were monitored. The results showed that although there were
no significant changes noted, infants in the post intervention group had better feeding
initiation and improved breast milk feeding at time of discharge. The suggestion is that
the educational intervention in increasing nurse knowledge about breast-feeding made a
difference.
44
Similarly, Siddell, Marinelli, Froman, and Burke (2003) used a pretest and
posttest study design to compare the effect of breast-feeding education on the NICU and
pediatric medical surgical nurses’ knowledge and attitude about breast-feeding. The
purpose of their study was to understand what influences nurses’ behaviors toward
breast-feeding mothers. The researchers postulated that understanding what influences
nurse behavior is important to the success or failure for a breast-feeding mother in the
NICU. The study showed that a year after the educational intervention 69% of admitted
infants received breast milk in comparison to 65% in the prior year, and 59% of mothers
continued to provide breast milk or breast-feed their infants compared to 49% in the prior
year. Their findings suggested that there was a significant improvement in nurses’
knowledge (p<.001), with a change in certain but not all attitudes about breast-feeding by
NICU mothers.
Rogers, Babgi, and Gomez (2008) used a pretest, intervention, and posttest design
to assess improvement in the nursing care of dying infants. In providing the educational
intervention, the purpose of the study was to help NICU nurses become more
knowledgeable and comfortable caring for dying infants and their families. Areas
analyzed in the study included pain and symptom management, ethical/legal issues,
communication/culture, spirituality/anxiety, and the prevention of compassion fatigue.
The pretest and posttest comparison of the different areas analyzed suggested the
following: (a) ethical/legal issues and symptom management had statistically significant
differences (t(10) =2.30, p<.05); (b) pain management, anxiety/spirituality, and
compassion fatigue had higher mean scores after the intervention, though not statistically
significant differences (t(14) =1.47, p=.259); and (c) communication/culture had lower
45
module scores following the intervention with no statistical difference (t(17) =-0.11, p
=.917). The authors concluded that an educational intervention can benefit NICU nurses
in the provision of better care for dying infants and their families.
Regardless of what educational method was used, there was consistent
improvement in practice outcomes (Siddell et al., 2003). Providing nurses the needed
tools allows for more confidence and empowerment to advocate for patients. While a
hospital in an urban center may transition an LPI into a level two nursery, another
hospital in a rural center may transition an infant of similar gestational age into a level
one nursery. It therefore is important to educate nurses in the areas of practice that have
deficiencies. Patients depend on nurses for quality care regardless of location; therefore,
necessary tools must be available in order to provide such anticipated care.
Education in Caring Behaviors
Results of these studies suggest that educational intervention has an influence on
the nurse practice environment. Although the literature on outcome issues concerning the
LPI can guide treatment decisions, caring behaviors as described previously can be used
in clinical practice, complementing a structured protocol. “Patients’ outcome depends on
the nurses’ ability to engage another’s reality through an empathetic caring sense”
(Hanson, 2004, p. 23). Swanson’s (1991) definition of caring and the five caring concepts
have relevance to both formal and informal LPI caregivers while providing a framework
for their caring. Providing care using Swanson’s theory of caring will ensure a positive
nurse-parent relationship, which has been identified as the most influential factor
affecting parents’ satisfaction with the experience of caring for their newborn (Reis,
Rempel, Scott, Brady-Fryer, & Von Aerde, 2010).
46
Summary
Several studies have indicated there are risks associated with the LPI and that
further interventions are needed to reduce associated costs and ensure positive outcomes
for this group of infants. Moreover, despite the identified need to educate health care
providers on LPI care to reduce mortality and morbidity, there remains a lack of
empirical studies on LPI educational intervention, especially for nurses. Very few studies
have focused on how to appropriately care for this population of infants with emphasis on
their specific needs. Educating health care professionals, particularly nurses, on the care
of the LPIs has been identified as a priority in improving outcomes (Baker et al., 2009;
Jorgensen, 2008b; Shaw, 2008). A knowledge-practice gap still exists, and increased
caregiver education remains a necessity. Therefore, this study examined the effectiveness
of a late preterm infant educational intervention incorporating Swanson’s (1991) theory
of caring on the knowledge of nursery and post partum nurses and the effect of such an
intervention on LPI outcomes for hyperbilirubinemia and dehydration. “Caring for the
LPI requires understanding of the high risk and specialized nursing skill, clinical
vigilance and more frequent monitoring of vital signs and other relevant clinical
parameters and increased laboratory testing” (Medoff-Cooper et al., 2005, p. 668). Well-
informed caring nursing staff will influence the decisions made in nursing care of the
LPI.
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CHAPTER THREE
METHODOLOGY
The purpose of this quasi-experimental repeated measures one group pretest-
posttest study was to examine the effect of an educational intervention using Swanson’s
(1991) caring theory on nurses’ knowledge regarding care provided to LPIs and their
families, and the incidence of LPIs’ hospital visits and readmission rates for
hyperbilirubinemia and dehydration in the first 30 days of life. The research questions
that guided this study were:
1. What is the effect of a late preterm infant educational intervention on
knowledge among practicing nursery and post partum nurses?
2. What is the effect of a late preterm infant educational intervention based on
Swanson’s theory on caring behaviors among practicing nursery and post
partum nurses?
3. What is the effect of a late preterm infant educational intervention program on
the incidence of hospital visits and readmission rate for hyperbilirubinemia in
the late preterm infant during the first 30 days of life?
4. What is the effect of a late preterm infant educational intervention program on
the incidence of hospital visits and readmission rate for dehydration in the late
preterm infant during the first 30 days of life?
48
Research Design
The effect of an educational intervention on nurses’ knowledge of and caring
behaviors to late preterm infants was evaluated using a quasi-experimental, repeated
measures one group pretest-posttest design. In addition, the effect of the educational
intervention on hospital visits and readmission rates for hyperbilirubinemia and
dehydration within the LPI’s first 30 days of life was measured to evaluate impact on
health outcomes. A controlled experimental design was not used in this study because
causal relations are difficult to establish. Applying controls also is not possible nor easily
adaptable in the real world. A quasi-experimental design was used to estimate the impact
of an educational intervention on nursery and post partum nurses. Quasi-experimental
designs may be the only way to evaluate the effect of an independent variable of interest
in a practice setting (Creswell, 2003; LoBiondo-Wood & Haber, 2006). The study
limitations in using a quasi-experimental design are discussed later in the report section.
The nurses’ pre-intervention scores were used as baseline for the study and the nurses’
repeated post intervention scores and LPI hospital visits and readmission for
hyperbilirubinemia and dehydration as the outcomes. The effect of the educational
intervention on the nurses’ knowledge of the LPI using the pretest and posttest and the
nurses caring behaviors using Swanson’s (1991) modified tool was determined within
one group. In addition, to determine the hospital visits and readmission rates for
hyperbilirubinemia and dehydration within the first 30 days of life, hospital generated
reports on LPIs were used.
The study included an initial assessment of participants’ knowledge of the late
preterm infant using the AWHONN (2010) “Assessment and Care of the Late Preterm
49
Infant: Evidence-based Clinical Practice Guideline” posttest questions, hereafter referred
to as the late preterm infant knowledge assessment instrument (LPI-KI). AWHONN
originally intended the program as an “open book” continuing education exercise for
perinatal nurses. The tool was developed to measure nurses’ knowledge of the LPI using
the nursing care guidelines recommended by AWHONN in order to provide safe, quality
care for the LPI in the clinical setting. This investigator received permission from
AWHONN to use the posttest as an instrument in the study to measure the nurses’
knowledge of the LPI. The instrument is a 20-item multiple-choice questionnaire
developed from evidence-based practice guidelines. However, since psychometric
properties of the LPI-KI have not been examined in previous studies, a content validity
study was conducted before its use in this study. Content validity was established through
a panel of experts who were selected for their expertise as scientists and clinicians
dedicated to improving the health and well-being of the LPI and their families. Of the 30
letter of invitations for participation sent out, a sample of 10 experts was recruited for the
content validity. Their credentials included assistant, associate, and full professors as well
as advanced clinical nurse specialists with expertise in late preterm infant care.
The modified Caring Professional Scale (CPS), referred to as the Late Preterm
Infant Caring Professional Scale (LPI-CPS), is a self-assessment of nurses’ caring
behavior. The original tool was developed to measure consumers’ perception of the
relationship styles of health care professionals. With permission from the developer, Dr.
Kristen Swanson, the instrument was modified. In its modified version, the instrument is
a self-assessment tool of the health care provider’s perspective of their own ability to care
for LPIs and their families. The tool is a 15-item, Likert-type instrument that asks
50
responders to circle the words that best describe the way they experience the care they
provided to LPIs and their families.
Intervention tools
The AWHONN Assessment and Care of the Late Preterm Infant
This evidence-based clinical practice guideline was developed by the Late
Preterm Infant Development Team, a subcommittee of the Late Preterm Science Team.
The team’s “goal includes increasing health care provider and consumer awareness of the
risks associated with the LPI and ensuring that evidence-based educational resources and
guidelines are available to assist nurses and other health care providers to provide
appropriate assessment and care for these vulnerable newborns” (AWHONN, 2010, p.
1). Members of the team were selected for their expertise as scientists and clinicians
dedicated to improving maternal/newborn health (AWHONN, 2010). The committee of
experts designed the educational program content based on the significance of the LPI
and evidence-based clinical practice guidelines.
The Caring Professional Scale
The original tool was developed to measure consumers’ perception of the
relationship styles of health care professionals. The instrument has been modified for this
study as a self assessment tool of health care providers’ perspectives of their ability to
care for the LPI and their families.
Waltz, Strickland, and Lenz (2004) recommended two or more content specialists
provide expert view of an instrument. However, Lynn (1986) indicated that complete
agreement must exist among reviewers in studies with seven or fewer experts. Attempts
were made to recruit at least 7 experts for each instrument, and although 10 experts were
51
recruited for the LPI-KI instrument, only 5 were recruited for the content validity of the
LPI-CPS. In the study, credentials for the experts included assistant, associate, and full
professors and clinical nurse specialists with expertise in late preterm infants care and in
caring theory.
Lynn (1986) proposed a two-step method for determining content validity.
Experts were individually provided copies of the instrument, the purpose, and study
objectives. For assessment of the knowledge instrument (Appendix F), these panel
experts reviewed it as well as all instructions given. Each expert evaluated each item
separately as well as the overall test. For the LPI-CPS (Appendix G), each expert
evaluated the relevance of individual items to the LPI objectives using a 4-point Likert
scale ranging from 1 = strongly disagree to 4 = strongly agree.
Of the 30 letters of invitations for participation sent out, a sample of five experts
was recruited for the content validity. After all responses had been collected from the
panel of experts for both instruments, Content Validity Index (CVI) was determined to
quantify the extent of agreement between experts. The CVI for the instrument is the
percentage of the total items rated as a 3 or 4. Though an acceptable level of inter rater
agreement varies from situation to situation, “safe guideline for an acceptable levels are
P0 value greater than or equal to 0.80, or K greater than or equal to 0.25” (Waltz et al.,
2004, p. 177). No revisions were made to the instruments since there were no panel
recommendations to do so. Based on this measurement of content validity, the LPI-KI
and the LPI-CPS were deemed appropriate measurements tools for this study.
The participants completed an educational intervention based on the associated
risk and the nursing management of the LPI incorporating Swanson’s (1991) theory of
52
caring. Participants’ knowledge was assessed following the intervention at two additional
intervals. The purpose of the two-time tests was to determine if any significant changes
occurred based on the educational intervention. This process included the following: (a) a
pretest using the LPI-KI, self assessment using the LPI-CPS instrument, and
demographic data collection; (b) an educational intervention that incorporated Swanson’s
(1991) theory of caring; (c) a posttest using both the LPI-KI and LPI-CPS following the
intervention; and (d) a posttest using the LPI-KI and the LPI-CPS 30 days after the
educational intervention. Measures for outcomes for LPIs delivered one month before
and one month after the intervention was collected at the intervention hospitals. Hospital
visits and readmission rates for LPIs with diagnoses of hyperbilirubinemia and
dehydration were compared to determine if there were any significant changes noted.
Using ICD codes for dehydration and hyperbilirubinemia (without patient identifiers),
hospital generated reports were used to make the comparison.
Outline for Educational Intervention
The educational intervention was conducted in a classroom setting where several
desk computers were housed. In total, 18 sessions were held at different times and dates
within a 2-week period. Participants were required to attend one session and attendance
ranged from 2-10 participants per group with a total of 72 participants in attendance. This
investigator presented the information using a PowerPoint demonstration (Appendix H).
Each session lasted an average of two hours and ten minutes. The learning objective was
to improve nurses’ knowledge of the risks and the unique needs of the LPI to facilitate
timely assessment and scientifically derived intervention (AWHONN, 2010). Session
discussion included how to incorporate Swanson’s (1991) caring theory in the nursing
53
management of LPIs and their families. The content outline included elaboration of the
following subheadings from the AWHONN evidence-based clinical practice guidelines:
• The learning objectives
• Introduction: Definition and prevalence
• The significance of the LPI: Overview and associated risk factors
• Nursing interventions and assessment
o Gestational age
o Respiratory distress
o Thermoregulation issues
o Hypoglycemia
o Sepsis
o Hyperbilirubinemia
o Hypoglycemia
o Feeding challenges
o Parent teaching and support
o Discharge planning
• Nursing application of Swanson’s theory of caring to the LPIs and families
o Swanson’s definition of caring concept
o Concepts illustrating caring
Knowing
Being with
Doing for
Enabling
54
Maintaining belief
o Conclusion and references
Study Method
The purpose of this study was to examine the effect of an educational intervention
on practicing nurses’ knowledge and caring behavior related to the care of the LPI and on
LPI outcomes for hyperbilirubinemia and dehydration at 30 days of life. All study
participants completed a pretest data collection form as a baseline when enrolling in the
study. The group then participated in the educational intervention that is based on the
associated risks and nursing management incorporating Swanson’s (1991) theory of
caring for the LPI. The participants then completed a posttest data collection immediately
following the educational intervention. There followed a period of one month after the
last educational intervention session during which time the participants were able to
implement the treatment in the practice setting. They then repeated the same posttest one
month after the last educational intervention session because, according to Machin,
Campbell, Fayer, and Pinol (1997), repeated measurements increase the power of a study.
Health care system generated reports of LPI outcomes for hospital visits and
readmission rates for hyperbilirubinemia and dehydration were obtained. A comparison
of readmission and hospital visits for LPIs with diagnosis-related groups (DRG) coding
of hyperbilirubinemia and dehydration were compared from one month before and one
month after the educational intervention. The goal was to determine if there were any
significant changes noted.
Schematic representation of the study design is shown in Figure 1.
55
O1---------------X----------------------O2---------------------O3 LPI measures1
Pretest Educational intervention over a 2-week period
Posttest after educational intervention
Repeat posttest one month after educational intervention
LPI measures2
Figure 1. Design Study. LPI measures1 = data collection one month before educational intervention X = Educational intervention O1 = Pre test of nurses’ LPI knowledge and self assessment of caring behaviors O2 = Post test of nurses’ LPI knowledge after educational intervention O3 = Post test of nurses’ LPI knowledge and self assessment of caring behaviors one
month after educational intervention and implementation in a practice setting LPI measures2 = data collection one month after educational intervention
Sample
Study participants were registered nurses with at least one year of experience
working in the newborn nursery or postpartum care units in an accredited health care
system in southeastern Florida. The participants’ inclusion criteria in the study were
nurses who have completed at least one year experience working with well newborns,
who have attended the educational intervention session, and who have completed tests at
the three intervals. The decision was made to use the stated criteria because the
population of infants who are being studied usually are admitted to the post partum units.
The sample size was determined using the G*Power 3.1 software (Faaul,
Erdfelder, Buchner, & Lang, 2009), based on a power level of .80 and significant alpha
level of .05 and with a moderate effect size of .15. These levels have been suggested in
most health science quantitative studies found in the literature. The specification of a
moderate effect size and the required power is considered reasonable and practical
(Duffy, 2006; Faaul et al., 2009; Machin et al., 1997). The result of the power analysis
suggested that a sample size of 73 would be adequate. In order to detect the effect,
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difference, or relationship in a study result, there needs to be a sufficient number of
participants. However, recruiting too many participants might not be cost effective and
may lead to the inefficient use of valuable resources (Duffy, 2006; Faaul et al., 2009;
Nunnally & Bernstein, 1994). In anticipation that some participants might not complete
all requirements, an attempt was made to add an additional 10% to the sample size,
bringing the needed number of participants to a total of 80. This would ensure that the
sample size remained sufficiently high to avoid committing a type 1 or type 2 errors at
the originally prearranged levels of 0.05 value and .80 power level.
Sampling Method
Due to the availability of nurses, a convenience sampling methodology was used
to recruit participants. The drawback is that this population is not representative of the
general population and results can be generalized only to the institution where the study
was conducted. All volunteers were screened to ensure they met the inclusion criteria. An
introductory letter explaining the purpose of the study was provided to all volunteers, all
questions were answered, and informed consent was obtained. Participants were informed
that they could withdraw at any time during the study without penalty. The potential
benefits explained to participants included: (a) the nurses’ increased knowledge to care
for the LPI, (b) the LPIs receiving appropriate care, (c) better infant care being taught to
prepared and satisfied parents, and (d) potential reduction in LPIs’ hospital visits and
readmission rate for dehydration and hyperbilirubinemia. There were no more anticipated
risks to the participants than those encountered in the everyday professional life of the
nurse participants.
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Setting
The study was conducted at southeast Florida health care system hospitals with an
average of 10,000 births annually. The health care system has six hospitals, but only three
have maternity departments. The first hospital has a 20-bed level 2 Newborn Intensive
Care Unit (NICU), a 40-bed mother-baby unit, and an admitting newborn nursery. The
second hospital has a 12-bed level 2 NICU, a 36-bed mother baby unit, and an admitting
nursery. The third hospital has a 70-bed level 3 NICU, a 45-bed mother baby unit, and an
admitting nursery. The third hospital eventually was eliminated since there were no
volunteers. Throughout the health care system hospitals, LPIs in the 35.1-36.6 weeks are
cared for in mother-baby units and all infants 35 weeks or less are admitted to the NICU
for further evaluation and treatment.
Protection of Human Subjects
Before data collections began, Institutional Review Board (IRB) approval were
obtained from Florida Atlantic University (Appendix I) and the health care system
hospitals participating in this study (Appendix J). Additional approvals were obtained
from the chief nursing officers (CNO) of the three hospitals that the investigators had
hoped would participate in the study (Appendix K). However, one of the hospitals had no
volunteers so the study ended up being done in two of the three hospitals. After all
approvals had been completed, recruitment in the local hospitals was done by flyers
(Appendix L), word of mouth, and email distribution to nursery and post partum
registered nurses. An explanation of the requirements for participation was provided and
consent obtained from those willing to participate (Appendix M). Confidentiality was
maintained since the investigators did not have any identifying markers for the
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participants. As they completed the pretest, the participants were asked to place a 4-
number code meaningful only to them on the upper right hand corner of the pretest. All
pretest and posttest forms were identified only by matched numbers to protect
confidentiality. Participants were advised to write the number somewhere where it was
safe and easily retrievable for use in repeated tests. They were informed that, upon
completion of the study, findings would be presented as group data with no personal
information reported.
Data Collection Procedures
Because the study was being conducted on active nursing units, the pretest,
posttest and educational intervention were scheduled with participants. In order to reach
all enrolled participants and to minimize scheduling difficulties, the sessions were
conducted in small groups over a 2-week period. In an attempt to reach the target sample
size, multiple sessions scheduled at different hours and days of the week ensured high
participation and the ability to reach off shift staff.
At each intervention session, this investigator presented a study overview to staff
at times determined in collaboration with the unit managers. This investigator provided a
verbal overview of the study and answered all related questions. Prior to the educational
intervention, all participants were asked to complete a computer-based LPI knowledge
and caring behavior pretest (using the LPI-KI and LPI-CPS) as a baseline. The
pretest/posttests were posted online through Survey Monkey® and were administered to
the nurses before and after the educational intervention. The nurses had access to the
survey through a link to the survey site. After the pretest was completed, the PI provided
a 2-hour educational intervention to all participants. The intervention focused on
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information obtained from the AWHONN (2010) “Assessment and Care of the Late
Preterm Infant: Evidence-based Clinical Practice” guidelines. The guideline information
includes the following elements: gestational age assessment, sepsis, hypoglycemia,
respiratory and thermoregulation issues, jaundice and hyperbilirubinemia, feeding
challenges, and parent teaching and support. The objective was to improve nurses’
knowledge of the risks and the unique needs of the LPI to facilitate timely assessment
and scientifically derived intervention (AWHONN, 2010). Session discussion included
how to incorporate Swanson’s (1991) caring theory in the nursing management of LPIs
and their families.
Through the Survey Monkey® link, the participants completed a computer-based
knowledge posttest immediately following the intervention sessions. Two continuing
education units (2 CEUs) certificates were given to all participants after the posttest was
completed. In order to complete a 1-month follow up, a separate e-mail account was set
up, through Survey Monkey®, which allowed participants to provide their contact
information. This allowed separation of survey responses and participants’ contact
information and maintained anonymity of responses to the researcher.
Following a discussion period, study participants completed the posttest. In order
to minimize contamination, the participants were asked not to discuss test items with their
colleagues who may be attending later sessions. It is assumed that participants
immediately would implement LPI nursing care strategies in the practice setting.
Therefore, a 1-month post intervention assessment period was planned. Participants then
repeated the computer-based posttest (second posttest). Participants automatically were
sent the access e-mail providing the link to the survey site 30 days after completing the
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educational intervention. They were encouraged to complete the second posttest at their
convenience within a 2-week period of receiving the e-mail invitation. In order to
increase response rates, two scheduled reminders were planned. For this study, the first
reminder was sent three days after the initial invitation, with a second and final reminder
sent on day 6.
The impact of the educational intervention was measured by the posttest scores.
An improvement in the scores reflected improved knowledge. The pretest was used as a
baseline score. The posttest and 1-month follow-up scores were outcomes as well as
hospital visits and readmission rates for LPIs with diagnoses of hyperbilirubinemia and
dehydration. Hospital generated reports were collected from the health care system
decision support department. The report included all LPIs’ hospital visits or readmissions
with a DRG-coded diagnosis of dehydration and hyperbilirubinemia. The report
collection period was one month prior to and one month after the completion of the
educational intervention. The collected data were analyzed for assessment of the effect of
the educational intervention following treatment implementation in the practice setting.
Study Data Analysis
Both descriptive and inferential statistics were evaluated. Data collected were
analyzed using the SPSS for Windows (21). Cronbach’s coefficient alpha was used to
analyze the internal consistency of the two instruments. Research questions were
analyzed using descriptive statistics (means, standard deviation, percentages, frequency,
range, and mode) for demographic characteristics of participants. A repeated measure
ANOVA and Fisher’s Exact test were used for comparing participants’ test scores at
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different intervals. Fisher’s Exact test was used due to the low incidents reported for LPI
outcomes. Research questions were analyzed as follows:
Research Question 1. What is the effect of a late preterm infant educational
intervention on knowledge among practicing nursery and post partum nurses?
Research Hypothesis 1. There will be a significance positive difference in the
knowledge of practicing nursery and post partum nurses after an educational
intervention.
Research Question 2. What is the effect of a late preterm infant educational
intervention based on Swanson’s theory on caring behaviors among practicing nursery
and post partum nurses?
Research Hypothesis 2. There will be a significant positive difference in the
caring behaviors of nursery and post partum nurses following the educational
intervention.
Research Question 3. What is the effect of a late preterm infant educational
intervention program on the incidence of hospital visits and readmission rate for
hyperbilirubinemia in the late preterm infant during the first 30 days of life?
Research Hypothesis 3. Following an educational intervention, there will be a
significant decrease in the incidence of hospital visits and readmission rate for
hyperbilirubinemia in the first 30 days of life for the LPI.
Research Question 4. What is the effect of a late preterm infant educational
intervention program on the incidence of hospital visits and readmission rate for
dehydration in the late preterm infant during the first 30 days of life?
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Research Hypothesis 4. Following an education intervention, there will be a
significant decrease in the incidence of hospital visits and readmission rate for
dehydration in the first 30 days of life for the LPI.
A total score from the LPI-KI was calculated by summing up all the responses
from the form. Frequency distribution and descriptive statistics including means, standard
deviation, range of scores frequencies, and percentages were used to describe the
characteristics of the participants and to provide an initial description of changes in
nurses’ knowledge. An ANOVA repeated measure within factors was used to examine
the statistical significance of changes in mean scores between (a) pretest and posttest O2,
(b) pretest and posttest O3, and (c) posttest O2 and posttest O3. Repeated measure
design, an approach that helps to deal with individual differences, is used to measure the
same variable over time on a group or groups of participants (within group measure).
“Each participant serves as his or her own control and the within or error variance will be
reduced” (Munro, 2005, p. 202). Since it is impossible to account for all the factors that
might affect an observed score, the assumption is that the differences in the nursery and
post partum nurses’ test scores correctly reflect their knowledge regarding the late
preterm infant. According to the classic test theory, “a test’s reliability reflects the extent
to which the differences in respondents’ test scores are a function of their true
psychological differences, as opposed to measurement error” (Furr & Bacharach, 2008, p.
82).
Cronbach’s coefficient alpha was used to obtain an estimate of internal
consistency reliability for the test scores. Since the items will be scored 1 if correct and 0
if incorrect or missing, the alpha coefficient was calculated to determine the internal
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consistency of the 20-item instrument. According to Polit and Beck (2008), the normal
range of value is between .00 and +1.00; while .70 might be sufficient, .80 or greater is
desirable. Nunnally and Beinstein (1994) said that, “if important decisions are made with
respect to specific test scores, a reliability of .90 is the bare minimum and a reliability of
.95 should be considered the desirable standard” (p. 265). Coefficient alpha measures
both the consistency within the instrument and the degree of correlation of items that
measure the same concept.
The overall score of the test was computed from the responses to the items on the
test. An item response theory (IRT) approach was used to model the response; the
difficulty of an item and the ability of the nursery and post partum nurse then can be
compared. A computation of the Cronbach’s alpha on each group of items shows a strong
correlation if the items measure the same construct; it then is assumed that part of the test
is likely to be reliable. A high correlation between an item and the total score is
considered indicative of the reliability of the item. Consideration in assessing the
instrument is the notion that internal consistency reliability is affected by two factors, the
length and the consistency among the test items; then, reliability can be equated with the
stability consistency of the instrument. Stability reliability can be determined by
completing a test-retest reliability estimate using Spearman rho correlation coefficient
formula.
The same posttest is administered to the same group of participants at different
times, preferably at an interval of two weeks to one month (DeVon et al., 2007). The
correlation co-efficient, an important instrument for describing the degree or direction of
a relationship, is used: “The correlation between the two scores, and often between
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individual questions, indicate the stability of the instrument” (De Von et al., 2007, p.
160). A high correlation is generally r> .70.
A statistical analysis of the LPIs’ readmission and hospital visits for
hyperbilirubinemia and dehydration was completed. ANOVA was used to analyze the
data collected one month prior to educational intervention and one month after the
completion of the educational intervention. Due to low incidents reported, a Fisher Exact
test was performed in the Post Hoc analysis to determine whether the treatment
intervention had any effect on LPI readmission for hyperbilirubinemia and dehydration.
This was determined by the number of LPIs with DRG for hyperbilirubinemia and
dehydration before and after the educational intervention.
Assumptions and Study Limitations
The basic assumptions are that the correlation between the first (pretest), second
(posttest O1), and third (O2) scores are the same and that there are no interactions
between the study group and time, i.e., the carry-over effect.
The sample size, although selected from the target population, may not be large
enough to be representative of the target population to which the finding will be
generalized. The characteristics of the sample, the environment, or the research situation
may limit generalization of research findings. Furthermore, without a control group, one
cannot conclude with certainty that any result obtained in the current study will be as a
result of the educational intervention.
Internal validity is the extent to which the result can be viewed as a true reflection
of reality rather than due to other extraneous variables. A threat identified in this study
was instrumentation threat. There were concerns for selection bias if only nurses who are
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the most experienced volunteer to participate. The other threat may be the measurement
effect since the instrument used has not been tested in this population and may not be
applicable to another group of participants who are not exposed to the same data
collection procedure. The significance of a study sometimes depends on the situation and
types of people to which the result can be generalized.
Summary
The study attempted to establish the psychometric properties of two instruments
that were used to assess the effect of an educational intervention on nurse LPI knowledge
using Swanson’s (1991) caring theory, and the effect of knowledge on the incidence of
LPI hospital visits and readmissions for hyperbilirubinemia and dehydration in the first
30 days of life. The participants were nursery and post partum nurses who attended a 2-
hour educational intervention on risk associated with the LPI and on their nursing
management incorporating Swanson (1991) caring theory. Analyses included descriptive
statistics and ANOVA repeated measures.
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CHAPTER 4
STUDY RESULTS
The purpose of this study was to examine the effect of an educational intervention
using Swanson’s (1991) caring theory on (a) nurses’ knowledge and caring behavior to
late preterm infants and their families, and (b) the incidence of LPIs’ hospital visits and
readmission rates for hyperbilirubinemia and dehydration in the first 30 days of life. This
chapter presents the results of the quasi-experimental pretest-posttest method used in the
study and is organized into four sections. The first section contains the content validity
index (CVI) of the two instruments used in the study. The second section contains
descriptive statistics items on the instruments. The third section contains primary analysis
of the study. The fourth and final section contains the conclusions, with a summary of the
study results. The results of the study as they relate to the research questions are
presented in both tabular and graphic format, with explanations of these diagrams in the
surrounding text. Analyses were completed using Statistical Package for the Social
Sciences (SPSS) for Windows (21). All significance levels were set a priori at α of 0.05.
Psychometric Analysis
To strengthen the findings in this study, a content validity study was conducted in
the first phase of this project. Initial testing of the study instruments, the LPI-KI for
knowledge assessment and the LPI-CPS for caring self assessment, was necessary before
use for research purposes. Neither of these instruments has been used in research projects
in the past and their psychometric properties have not been demonstrated. In the
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preliminary study, a panel of experts who are versed in LPI care issues was recruited. The
PI sent a letter of invitation to 30 experts who are versed in LPI knowledge to evaluate
the content of the knowledge tool. An additional 30 invitations were sent to experts in
caring theory to evaluate the content of the modified caring tool. Ten of the knowledge
and five of the caring experts completed the surveys. The final panel represented a range
of expertise in LPI care including assistant and full professors as well as a clinical nurse
specialist.
Content Validity
How an instrument is used is determined by how well the instrument meets the
theoretical expectation. Validity refers to the extent to which a measurement in fact
measures the purpose for which it is intended (Carmines & Zeller, 1979; Waltz et al.,
2004). Although support for the validity of an instrument is determined by examining the
content, construct, and criterion related concepts, only content validity was determined
for this study. Polit and Beck (2008) stated that “content validity is crucial for tests of
knowledge” (p. 328). Carmines and Zeller (1979) believed that this “depends on the
extent to which an empirical measurement reflects the domain of content” (p. 20). The
central question in examining validity of the LPI-KI and the LPI-CPS was to determine
how well the instruments reflect a fair range of elements relevant to caring for the LPI.
Experts on both instruments were sent an e-mail inviting them to participate in
evaluating the content of both instruments. The e-mail had a copy of the instrument
attached and an explanation of the objectives of the tools. For the LPI-KI, it was
explained that the objective was to assess nurse knowledge of the risks associated with
the LPI. The caring tool objective was to assess nurse self assessment of their perception
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of caring behavior towards the LPI and families. It was explained that the central
question in examining validity of the LPI-KI and the LPI-CPS was to determine how well
the instruments reflect a fair range of elements relevant to caring for the LPI. Three
weekly reminders were sent to encourage experts’ participation. In spite of the reminders,
within a 4-week period, only 10 experts responded to the knowledge instrument and 5 to
the caring instrument.
For the LPI-CPS, the experts evaluated each item for: (a) knowledge of caring,
(b) focus and relevance to Swanson’s theory concepts, (c) clarity and understanding, and
(d) appropriateness to participants. For the LPI-KI, each item was evaluated for: (a)
content, concepts, and knowledge with focus on LPI associated risks; (b) clarity and
understanding of questions; (c) relevance to definition of LPI; and (d) logical sequence of
questions. The experts used a 4-point Likert scale from 1 = strongly disagree to 4 =
strongly agreed. The CVI for the instrument is the percentage of the total items rated as a
3 or 4. The experts in the LPI-KI and the LPI-CPS groups were 80% in agreement that
the tools met the criteria being measured. There were no items identified as inconsistent
with the content being measured.
Internal Consistency Reliability
Cronbach’s coefficient alpha was used to assess the internal consistency of the
two instruments. In using this statistical technique, the variance for each item and the
variance for the total scores were computed. The analyses determine the degree to which
all the items are measuring the same constructs. The alpha coefficient was calculated to
determine the internal consistency of the 20 items in the knowledge instrument and 15
items in the caring instrument. Fields (2013) rates Cronbach’s alpha results of less than
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0.6 = poor, 0.6-0.7 = questionable, 0.7-0.8 = acceptable, 0.8-0.9 = good, and >0.9 =
excellent. All items in the knowledge instrument were scored 1 if correct and 0 if
incorrect or missing. Items in the caring instrument were scored 5 = yes definitely, 4 =
mostly, 3 = about half and half, 2 = occasionally, and 1 = no, not at all. The overall scores
were computed from the participants’ responses to the items on the test. A computation
of the Cronbach’s alpha on each group of items showed a strong correlation of the items.
The variance for the knowledge instrument had an α=0.867 and the caring instrument had
an α=0.894, indicating high internal consistency. Table 1 presents the Cronbach’s alpha
for the 20 items of the knowledge instrument.
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Table 1
Cronbach’s Alpha for Knowledge
Knowledge Questions
Scale Mean If Item Deleted
Scale Variance If
Item Deleted
Corrected Item-Total Correlation
Cronbach’s Alpha If Item
Deleted
Knowledge Question 1 12.05 20.67 0.40 0.863 Knowledge Question 2 12.38 20.27 0.28 0.868 Knowledge Question 3 12.15 20.18 0.41 0.863 Knowledge Question 4 12.14 21.04 0.16 0.870 Knowledge Question 5 12.20 20.21 0.36 0.864 Knowledge Question 6 12.28 19.60 0.47 0.860 Knowledge Question 7 12.61 19.52 0.46 0.861 Knowledge Question 8 12.40 19.12 0.54 0.857 Knowledge Question 9 12.20 19.60 0.53 0.858 Knowledge Question 10 12.27 20.34 0.29 0.867 Knowledge Question 11 12.25 19.24 0.58 0.856 Knowledge Question 12 12.07 20.05 0.59 0.858 Knowledge Question 13 12.68 19.90 0.40 0.863 Knowledge Question 14 12.53 20.02 0.33 0.866 Knowledge Question 15 12.57 19.10 0.56 0.857 Knowledge Question 16 12.41 18.71 0.65 0.853 Knowledge Question 17 12.08 19.94 0.60 0.858 Knowledge Question 18 12.16 19.63 0.57 0.857 Knowledge Question 19 12.45 18.94 0.58 0.856 Knowledge Question 20 12.59 18.92 0.61 0.855
Note. Scale Cronbach’s α=.867.
The overall knowledge Cronbach’s alpha = 0.867. There were no problematic
items identified by the item analysis. Therefore all items were retained. Table 2 presents
the Cronbach’s Alpha for the 15 items of the caring instrument.
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Table 2
Cronbach’s Alpha for Caring
Caring Questions
Scale Mean If Item Deleted
Scale Variance If
Item Deleted
Corrected Item-Total Correlation
Cronbach’s Alpha If Item
Deleted
Caring Question 1 66.65 16.42 0.64 0.887 Caring Question 2 66.67 16.39 0.62 0.887 Caring Question 3 66.78 15.61 0.64 0.885 Caring Question 4 66.82 15.56 0.58 0.887 Caring Question 5 66.68 16.27 0.64 0.886 Caring Question 6 67.00 16.02 0.35 0.901 Caring Question 7 66.63 16.55 0.65 0.887 Caring Question 8 66.65 16.32 0.69 0.885 Caring Question 9 66.76 15.87 0.64 0.885 Caring Question 10 66.87 15.82 0.47 0.893 Caring Question 11 66.73 15.84 0.67 0.884 Caring Question 12 66.87 15.65 0.60 0.886 Caring Question 13 66.92 15.19 0.62 0.886 Caring Question 14 66.89 15.22 0.57 0.889 Caring Question 15 66.62 16.61 0.66 0.887
Note. Scale Cronbach’s α=.894.
The overall caring Cronbach’s alpha = 0.894. There were no problematic items
identified by the item analysis. Therefore, all items were retained.
Description of the Participants
Sample Characteristics
The data were collected online via Survey Monkey® from nursery and post
partum nurses in two local hospitals within one health care system in south Florida. The
study was advertised via fliers distributed at the nursing stations and staff lounges, by
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emails, and by word of mouth. The nurses were asked to call the PI if they were
interested in participating in the study. Schedules as to session dates and times within a 2-
week period were posted. Originally, permission was granted to collect data from
participants at one hospital within the health care system. Three times each week, the PI
went with doughnuts into the hospital twice daily at shift change in an attempt to recruit
participants. After one week without any volunteers, the PI sought and was granted
permission from the IRB to include the other two units within the health care system in
the study. Additionally, CNOs were approached to grant the PI permission to recruit
participants from the hospitals’ maternity units as collection sites. Participants that met
the inclusion criteria then were scheduled to attend the sessions. However, there were a
few walk-ins who also met the inclusion criteria and were included in the study.
Arrangements were made in advance with the health care system’s Information
Technology (IT) department to reserve rooms in their training center, where several
computers are housed. Several sessions were planned at different times and dates to
encourage participation. In total, 18 sessions were held within a 2-week period. The
number of participants who attended the session ranged from 2 per group to 10 per group.
The PI moderated all sessions. Upon arrival, participants were invited to partake of the
snacks consisting of juice, pastries, and crackers. The sessions began with participants
signing the online consent forms. Once the consent was signed, participants then were
redirected to the online demographic tool (Appendix N). They were asked to place a 4-
digit code that would be remembered easily and only known to them on each survey.
They also were aware that they would be using the same code one month later for the
follow up survey. After participants completed the demographic information, they
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automatically were redirected to the pretest page, first to the knowledge questions and
then to the caring self assessment questions. The knowledge questions focused on risks
associated with the LPI, while the caring questions focused on Swanson’s caring theory
concepts. After all participants had completed the pretest, the PI conducted the
educational intervention focusing on health risks associated with the LPI birth. The
caring theory then was presented following the knowledge presentation. During the
presentations, time was provided for questions and discussions. Some discussions were
more robust depending on the personalities and experience of the participants with LPIs.
The participants then completed the posttest and were given a 2-hour continuing
education unit (CEU) certificate as compensation for their participation. On average,
sessions lasted two hours and ten minutes.
The web-based survey manager sent e-mail reminders regarding the 1-month
follow-up data to all study participants using the e-mail address the participants provided
during the initial session. The e-mail provided the link to the 1-month posttest survey.
Since participation was anonymous, the PI could not track individual participation.
Therefore, a mass e-mail was sent out to all nursery and post partum nurses at the two
participating hospitals to remind them of the follow-up survey. The mass email served to
remind those who had participated in the study to check their email for the survey link as
discussed during the sessions a month earlier. Two scheduled reminder emails were sent
as planned. The first was three days after the initial invitation and the second and final
reminder was on the sixth day after the initial reminder.
In spite of the two reminders, only 47 of the 72 participants completed the third
survey. One of the challenges experienced was that some participants forgot their 4-digit
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codes. This investigator received telephone calls from participants asking for a reminder
of their codes. Since the survey was anonymous, this investigator had no way of
identifying which code belonged to whom. It is possible that additional participants than
those who called the PI did not complete the third survey due to this issue. Additionally,
it was a busy period on the nursing units, with summer vacations leading to staffing
shortages, high patient census, and high nurse-patient ratio assignments. The participants
were expected to complete the follow up survey at their convenience within a 2-week
period. The practice environment could have influenced the data collection as well.
Although IRB approval was for 80 participants, a total of 72 participants were
conveniently recruited for this study. Some of the recruitment challenges experienced
included:
• Five participants did not show because they had worked longer hours than
anticipated the previous nights.
• Three others did not attend and did not explain why.
• One participant attended with her two young daughters ages 3 and 4. She was
distracted providing care and entertaining her children during the session.
While she was physically present at the session, it is not clear that she was
authentically present.
Data were collected online at SurveyMonkey®.com (n=72). Four participants
were immediately excluded from the study due to failure to complete any instruments
other than the demographic survey. Eight participants completed all the instruments, but
some questions were left incomplete; these participants were excluded from the data
analysis. The final sample size of 64 participants completed the pretest and posttest
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(n=64) and 47 completed all three tests (n=47). Even so, this is a 65% return rate for all
three tests, considered a high survey return rate.
Other challenges experienced included that some of the participants were able to
contribute their prior knowledge of the LPI while others found the information relatively
new. Additionally, some of the participants were taking notes during the session of the
LPI knowledge information. This may have contributed to the high posttest scores. Since
one of the hospitals already has a caring theory as their culture most of those participants
were able to articulate the caring theory during the educational intervention. However,
they expressed more generalized knowledge of caring. They were unable to apply
Swanson’s caring concepts to the care of the LPI.
Demographic Characteristics of Participants
The final sample used in the demographic data analysis and summarized in Table
3 consisted of 72 registered nurses who work with newborns and their families. There
were demographic variations in the number of participants. The educational level varied:
1 (1.4%) had a doctorate in nursing (DNP); 7 (10%) had a Masters in nursing (MSN); 30
(42.9%) had a bachelors degree in nursing (BSN); 20 (28.6%) had an associate degree in
nursing (AS); 10 (14.3%) had a diploma in nursing (Dip); 1 (1.4%) had another
unspecified type of degree, and 3 (4.2%) did not respond to this question. It was a
pleasant surprise to have a high rate of participants (42%) with a BSN.
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Table 3
Demographic Characteristics of Participants (N=72)
Characteristics Frequency Percent Valid % Cumulative %
Highest Degree Associate 20 28.6 29.0 29.0
Diploma 10 14.3 14.5 43.5 BSN 30 42.9 43.5 87.0 MSN 7 10.0 10.1 97.1 Doctorate 1 1.4 1.4 98.6 Other 1 1.4 1.4 100.0
Age 20-30 1 1.4 1.4 1.4
31-40 10 14.3 14.3 15.7 41-50 29 41.4 41.4 57.1 51-60 25 35.7 35.7 92.9 >60 5 7.1 7.1 100.0
Race/Ethnicity White/Caucasian 25 35.7 35.7 35.7
Black/African American 22 31.4 31.4 67.1 Hispanic/Latino 9 12.9 12.9 80.0 Other 14 20.0 20.0 100.0
Marital Status Married 48 68.6 68.6 68.6
Single 11 15.7 15.7 84.3 Partnered 2 2.9 2.9 87.1 Divorced 7 10.0 10.0 97.1 Widowed 2 2.9 2.9 100.0
Prior Knowledge of LPI Yes 38 54.3 55.1 55.1
No 31 44.3 44.9 100.0 Year in OB
1-5 8 11.4 11.4 11.4 6-10 17 24.3 24.3 35.7 11-20 17 24.3 24.3 60.0 >20 28 40.0 40.0 100.0
Certification in OB Yes 33 47.1 47.8 47.8
No 36 51.4 52.2 100.0 Area of Certification
Low Risk Neonatal Nursing
4 5.7 10.5 10.5 Maternal Newborn 12 17.1 31.6 42.1 Inpatient Obstetric 10 14.3 26.3 68.4 Neonatal Intensive Care 7 10.0 18.4 86.8 Other 5 7.1 13.2 100.0
Note. Totals of the percentages are not 100 for every characteristic because of rounding and missing data.
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Participants’ ages ranged from 20-60 and were collected in categories (20-30, 31-
40, 41-50, 51-60, and >60). Of the 72 participants who responded to the question, 5
(7.1%) were over 60 years of age, 25 (35.7%) were in the 51-60 age range, 29 (41.4%)
were in the 41-50 age range, 10 (14.3%) were in the 31-40 age range, and 1 (1.4%) was
between 20-30 years of age. Two (2.7%) did not respond to this question. The age
distribution is representative of the current aging nurse population. Among the ethnic
groups, Caucasians had the highest representation with 25 (35.7%), followed by 22
(31.4%) for Black/African Americans, 9 (12.9%) for Latino/Hispanics, and 14 (20%) as
represented by other ethnic groups. Two (2.7%) did not respond to this question.
All participants responded to the question about marital status; 48 (68.6%) of the
participants were married, 11 (15.7%) were single, 2 (2.9%) were partnered, 7 (10%)
were divorced, and 2 (2.9%) were widowed. Two (2.9%) did not respond to this question.
Of the 72 participants, 38 (54.3%) had prior educational knowledge of the LPI,
while 31 (44.3%) had no prior educational knowledge of the LPI. Three (4.2%) did not
respond to this question. This question was included to identify difference in current
knowledge that may have had an effect on the results obtained. The participants had years
of obstetrical nursing ranging from 1 to 20. Of the 72 responses, 28 (40%) of the
participants had over 20 years experience, 17 (24.3%) had 11-20 years, 17 (24.3%) had 6-
10 years, and 8 (11.4%) had 1-5 years of experience. Two (2.9%) did not respond to this
question. Of the 33 (47.1%) that had certification in an area of obstetrical nursing, 12
(17.1%) were in maternal child, 10 (14.3%) were in inpatient obstetrics, 7 (10%) were in
high risk neonatal nursing, and 4 (5.7%) were in low risk neonatal nursing. A total of 36
(51.4%) had no certification in maternal newborn. Among the 33 nurses that were
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certified, 5 (7.1%) had certification in other unspecified nursing specialty and three
(4.2%) did not respond to this question.
Primary Findings
Statistical analysis of the data in this study included repeated measures analysis of
variance (ANOVA) and Fisher’s exact test. Repeated measures ANOVA was employed
to analyze change over time (Fields, 2013; Plichta & Kelvin, 2012; Stevens, 2009). This
methodology was used in this study to investigate changes across time from pretest to
posttest and 1-month follow up for knowledge and caring. Fisher’s exact test was used to
analyze readmission and hospital visits for hyperbilirubinemia and dehydration because
of the low incidences of observation across all cells
Research Hypothesis 1
The hypothesis stated that there will be a significance positive difference in the
knowledge of practicing nursery and post partum nurses after the educational
intervention. Knowledge about risks factors associated with the LPI was measured at
baseline (pretest), after the educational intervention (posttest), and at 1-month follow-up.
Possible scores were 0-20. Baseline mean knowledge scores were compared to mean
knowledge score after the treatment to determine if the intervention influenced
participants’ knowledge of the LPIs and their families. Further comparison was made
between the baseline mean scores and 1-month follow up mean scores. This hypothesis
was statistically significant with a repeated measures ANOVA producing a Wilk’s
Lambda (f=292.4, p<0.001, η2 .929) (Table 4). There were significant changes from the
pretest scores with a mean of 10.43, posttest scores with a mean of 17.83, and 1-month
follow up with a mean of 13.8. There were statistical significant gains from the pre to
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post (p<.001), and from pre to 1-month (p<.001). There was a significant decrease from
post to 1-month (p<.001), although the participants still retained a higher score than their
initial pretest scores.
Table 4
One-way Repeated Measures Analysis of Variance Investigating Change Over Time from Pretest to Post and One Month Follow-up for Knowledge and Caring
Pretest Posttest Month Follow-up
Mean SD Mean SD Mean SD F(λ) p η
Knowledge 10.43 1.77
17.83 1.45
13.81 2.28 292.4 <0.001 0.929
Caring 69.62 5.25 72.38 4.02 71.49 4.29 11.78 <0.001 0.389
Research Hypothesis 2
This hypothesis stated that there will be a significant positive difference in the
caring behaviors of nursery and post partum nurses after the educational intervention.
Caring behaviors for the LPI and their families was measured at baseline (pretest), after
the educational intervention (posttest), and at 1-month follow up. Possible scores were 0-
100. Baseline mean caring scores were compared to mean caring scores after the
treatment to determine if the intervention influenced participants’ caring behaviors to the
LPIs and their families. Further comparison was made between the baseline mean scores
and 1-month follow up mean scores. This hypothesis was statistically significant with a
repeated measures ANOVA producing a Wilk’s Lambda (f=11.78, p<0.001, η2 0.389)
(Table 5). There were significant changes from the pretest scores with a mean of 69.62,
and posttest scores with a mean of 72.38. There was no statistical difference between the
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posttest scores and 1-month follow up with a mean of 71.49 (p=0.159). There was
statistically significance between the pretest scores and the 1-month follow-up scores
(p=0.017). Pretest to posttest scores and pretest to 1-month scores show significant gain
(p<.001 and p=.017, respectively). However, there was a statistically significant decrease
in scores from posttest to 1-month (p=.159) (Table 6).
Table 5
Multiple Comparisons of Knowledge Change Over Time
Knowledge(1) (2) Mean Difference
(1-2) SD Error p
Pretest Posttest -7.404* .304 .000
1-Month -3.383* .387 .000
Posttest 1-Month 4.021* .377 .000
Table 6
Multiple Comparisons of Caring Changes Over Time
Caring (1) (2) Mean Difference
(1-2) SD Error p
Pretest Posttest -2.769* .565 .000
1-Month -1.872* .749 .017
Posttest 1- Month .897 .625 .159
Data for the hospital visits and readmission rates were retrieved from a health care
system report. The system wide report was selected to capture hospital visits or
hospitalization of infants who may be taken for care at facilities other than the one of
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their birth, although the expected incidence of an unscheduled hospital visit is low. This
was done in an attempt to capture infants who may not have returned to the birth hospital
within the health care system. Since there were low observed incidences (for less than 5)
for hyperbilirubinemia and dehydration, Fisher Exact tests were used to report p-values
for χ2.
Research Hypothesis 3
According to this hypothesis, following an education intervention there will be a
significant decrease in the incidence of hospital visits and readmission rate for
hyperbilirubinemia in the first 30 days of life for the LPI. In the 30-day period
immediately preceding the educational intervention, 35 LPIs were born. This data
provided the baseline rate of LPI births for the health care system. For these 35
specifically, 11.5% (n=4) had a return hospital visit for hyperbilirubinemia within the
first 30 days of life; one was readmitted due to hyperbilirubinemia. After the intervention,
although the rate of delivery remained the same (n=34), return hospital visits in the first
30 days of life for hyperbilirubinemia decreased to one infant (2.9% of the births); there
were no hospitalizations. Although this represented an 8.6% decrease in hospital visits,
the chi square analysis indicated that this was not a statistically significant difference.
This finding is likely due to the low incidence rate in these data. After Fisher exact
correction, however, the hospital visits rate for hyperbilirubinemia approached statistical
significance with a Fisher adjusted χ2 of 1.94 and p=0.085.
Hyperbilirubinemia has been identified as a major factor in readmission of LPIs
(Bhutani et al., 2006; Hillman, 2007; Meier et al., 2007; Pados, 2007; Shapiro-Mendoza
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et al., 2008; Shapiro-Mendoza et al., 2006). However, in the current study, the
demonstrated decrease in readmission was not significant (χ2=1.02, p= 0.314).
Research Hypothesis 4
This hypothesis stated that, following an education intervention, there will be a
significant decrease in the incidence of hospital visits and readmission rate for
dehydration in the first 30 days of life for the LPI. There were no incidents of hospital
visits for dehydration in either baseline or post intervention data. One newborn in the
baseline data was readmitted for dehydration; however, none of the infants born after the
educational intervention were readmitted for dehydration. While there was a decline in
incident rate, the number of LPI in this study likely affected analysis (χ2=1.02, p= 0.314)
(Table 7).
Table 7
Test of Changes in Hospital Visits and Readmissions from Before to After Educational Intervention
May (N=35)
July (N=34) χ 2(1) p
n %
n %
Hyperbilirubinemia Visits 4 11.40%
1 2.90% 1.94 0.085
Hyperbilirubinemia Readmits 1 2.90%
0 0.00% 1.02 0.314
Dehydration Visits 0 0.00%
0 0.00% - -
Dehydration Readmits 1 2.90% 0 0.00% 1.02 0.314
Note. Data is not from surveys but from a hospital generated report. Because of low incidences, Fisher Exact test were used to report p-values for χ2.
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Summary
The main purpose of this study was to determine the effect of an educational
intervention on knowledge and caring behavior of nurses caring for late preterm infants
and their families. The second purpose was to determine the effect of that educational
intervention on two outcome measures: late preterm infants’ hospital visits and
readmission rates for dehydration and hyperbilirubinemia in the first 30 days of life. Data
supported improved knowledge for all participants. There was a 37% increase in
knowledge from the baseline mean scores to the posttest mean scores (52% to 89%),
although there was a 20% knowledge decrease from the posttest to one month later (89%-
69%). There remained a true knowledge gain since knowledge increased between the
baseline measurements to the 1-month follow-up assessment (52% to 69%). Infant
outcomes related to hyperbilirubinemia and dehydration also demonstrated patterns of
improvement in the direction of statistical significance.
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CHAPTER 5
INTERPRETATIONS AND DISCUSSIONS
The purpose of this quasi-experimental repeated measures one group study was to
examine the effect of an educational intervention using Swanson’s (1991) caring theory
on: (a) the nurses’ knowledge regarding care provided to LPIs and their families, and (b)
the incidence of LPIs’ hospital visits and readmission rates for hyperbilirubinemia and
dehydration in the first 30 days of life. A review of the literature identified the increased
hospital costs associated with LPIs with great emphasis on the LPI readmission and
increased hospital visits for hyperbilirubinemia, poor feeding, and dehydration in the first
30 days of life (Institute of Medicine, 2006; Medoff-Cooper et al., 2005; Tomashek et al.,
2007). Additionally, lack of LPI knowledge among health care providers was identified
(AWHONN, 2010). Despite the increased interest in the LPI and lack of appropriate
guidelines in their care, little empirical research has been done from a nursing
perspective. Very few researchers have addressed how to appropriately care for the LPI
with emphasis on their unique needs.
Additionally, there were no studies identified that used a caring theory in this
population of infants. Therefore, this study examined the effect of using Swanson caring
theory in providing a nursing educational intervention in the care of the LPI and their
families. Using five concepts, Swanson describes caring as fostering a relationship with
another person with whom one feels committed and responsible. The concepts are
knowing, being with, doing for, enabling, and maintaining belief. These concepts make
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clear the caring actions that help build a positive relationship as the nurse interacts with
the patients and their families. (Swanson & Wojnar, 2004).
Discussion of Results
Research Questions and Interpretation
Research Question 1.What is the effect of a late preterm infant educational
intervention on knowledge among practicing nursery and post partum nurses? The
study results support the hypothesis that there will be a significance positive difference in
the knowledge of nurses after an educational intervention. Significant positive changes
emerged from the pretest mean scores to the posttest mean scores (m=10.43 to m=17.83)
given the short interval of time between the educational intervention and the posttest. At
1-month post educational intervention there was a higher knowledge mean score
(m=13.81) than baseline (m=10.43), which demonstrates that participants had a better
understanding of the LPI one month after the intervention than they did before the
educational intervention.
The current study was used to increase nurses’ knowledge of the risk associated
with LPIs. The premise in the current study is that the increase in knowledge contributed
to the outcomes of decreased rates of hospital visits and readmission. The explanation is
that as nurses became more knowledgeable about the differences in the care of an LPI,
their nursing intervention strategies changed. Studies in other infant populations (Pineda
et al., 2009; Rogers et al., 2008; Semelsberger, 2009; Siddell et al., 2003) have shown
that regardless of the educational intervention method used to impact knowledge, there
was consistent improvement in practice outcomes (Semelsberger, 2009; Siddell et al.,
2003).
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It is noted, though, that retaining information one month later was problematic for
the participants. The knowledge retention observed in this study are similar to those noted
in the literature. Tippett (2004) evaluated how well nurses’ knowledge increased after an
advanced trauma course and how well that knowledge was retained three months later.
Although there was a change in knowledge level across four time points (p<0.006,
p<0.018, and p<0.042), there was a significant reduction three months later. In a similar
study, Thompson, Harutyunyan, and Dorian (2012) evaluated the knowledge of health
care field workers in a 40-hour First Aid training course. The study assessed knowledge
retention, attitudes, and self reported practices at 6- and 18-month post educational
intervention. The second and third scores were closely related. However, there was a 19%
decrease difference in knowledge between the immediate posttest and at the 18-month
follow-up point. Similar to the current study, Thompson et al. (2012) suggested that
despite the decrease in knowledge beneficial and positive changes in the practice setting
existed.
It is unclear why the decrease one month later, despite implementation of the
newly acquired knowledge in the practice setting. With lower mean scores one month
later, could the participants have become careless with subsequent tests? According to
Munro (2005), practice with previous tests may increase scores on later tests or
participants may become bored by repeated tests that they become careless with later
tests.
Research Question 2.What is the effect of a late preterm infant educational
intervention on caring behaviors among practicing nursery and post partum
nurses? The results of this study did not support the hypothesis that there will be a
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significant positive difference in caring behaviors in the nursery and post partum nurses
following the educational intervention. Caring behaviors mean scores remained at
plateau, and there were minimal changes noted. Post-hoc analysis revealed significant
difference from pretest scores to posttest scores (p<0.001) and from pretest to 1-month
(p<0.017), but non significant differences from posttest scores to 1-month follow up
scores (p=0.159). There were minimal differences in the mean scores across the three
time points (m=69.62, 72.38, and 71.49). There was a statistically significant difference
in the baseline caring behavior and immediately following the educational intervention.
Also, an increase difference in mean scores emerged immediately following the
intervention and one month later; however, no statistical significance was associated with
the later increase.
The result correlates with other studies in the literature where no significant
findings were noted, but where caring behaviors may have been reinforced. In an
educational intervention study, Glembocki and Dunn (2010) used a pretest posttest design
in an attempt to enhance caring behaviors among nurses. In a 3-day seminar with 36
registered nurses, the authors used the Care Assessment of Caregivers (CAC) (a tool
similar to the caring tool used in the current study) as a tool and Reigniting the Spirit of
Caring as the intervention. The authors concluded that though a change in caring
behavior was not evident, the authors felt that they were able to help the nurses reflect on
self and caring behaviors. Blum et al. (2010) used a pretest posttest strategy as a new
model to teach a 15-week health assessment course to RN-BSN students. They concluded
that with the use of simulation technology, caring can be taught in nursing education.
Swanson (1999b) completed a meta-analysis of 130 studies on caring and concluded that
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an increase in family relationships and family support were noted when health care
providers displayed caring behaviors. The current study also is partly supported by the
Pineda et al. (2009) study of breast-feeding outcomes after an educational intervention.
The researchers postulated that in increasing the nurses’ knowledge and attitude about
breast-feeding, there was a more positive outcome with increased number of infants who
were breast-feeding.
Though there were minimal improvements noted in the LPI caring mean scores,
the improved caring perceived supports Swanson’s (1991) caring theory, the theoretical
framework guiding this study. The non significance may be related to nurses who already
are practicing caring, though not specific to Swanson’s concepts. There may not be a
need for improvement in caring behaviors due to the high level of knowledge of caring
noted at baseline (pretest). However, the educational intervention can be viewed as a
reinforcement of nurse caring behavior as evident in the pretest scores. The educational
intervention may have been a reinforcement of what was already known rather than new
knowledge for participants who already were versed in caring theory. Additional studies
are needed to further explore application of Swanson’s caring theory in the LPI
population.
Research Question 3.What is the effect of a late preterm infant educational
intervention program on the incidence of hospital visits and readmission rate for
hyperbilirubinemia in the late preterm infant during the first 30 days of life? The
results in this study did not support the hypothesis that there will be a statistically
significant decrease in hospital visits and readmission rate for hyperbilirubinemia in the
first 30 days of life following the educational intervention. Of the 35 LPIs delivered one
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month before the intervention, 11.5% (n=4) had a hospital visit for hyperbilirubinemia.
Of the 34 infants delivered following the intervention, 2.9% (n=1) had a hospital visit for
hyperbilirubinemia. While not statistically significant, it is an 8.6% decrease difference
for hospital visits for hyperbilirubinemia before and after the treatment. Though hospital
visits for hyperbilirubinemia has a low incidence reported in the current study, there is a
75% hyperbilirubinemia rate difference compared to other DRG reported. The high
percentage noted in this study supports findings by Bhutani et al. (2006), Shapiro-
Mendoza et al. (2008), Meier et al. (2007), and Pados (2007) in which each identified
hyperbilirubinemia as one of the most common reasons for readmission and hospital
visits in the first 30 days of life. On the contrary, Usatin, Liljestrand, Kuzniewicz,
Escobar, and Newman (2010) believed that parents of infants diagnosed with
hyperbilirubinemia overutilize outpatient services, and thereby had a higher incidence of
hospital visits. They claim that it is because these parents have an increased perception of
their infant’s vulnerability, and not necessarily because there is a need for such follow up
visits.
Though hyperbilirubinemia has been identified in the literature (Bhutani et al.,
2006; Shapiro-Mendoza et al., 2008; Meier et al., 2007; Pados, 2007) as a major factor in
LPI readmission in the first 30 days of life, the current study had only a 2.9% decrease
difference in readmission rate before and after the educational intervention. A
contributing factor for the low incident rate for outcome measures may be that a number
of the participants are well versed in the maternal child care environment. More than half
of the participants (54.3%) had prior knowledge of the LPI. Additionally, more than 60%
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have been working with infants for over 10 years and 47% have a certification in
obstetrics.
Despite the low incidence in the current study, some studies support higher LPI
readmission rate. Burgos et al. (2008) found high results in a population based trends of
infants (Term & LPI) who were readmitted for hyperbilirubinemia. Among this
population of infants, the LPI readmission rate was at <2 per 1000. The authors found
that one of the associated factors for readmission included gestational age 34-39 weeks.
The current study includes infants 34-36.6/7 weeks gestational age. According to the
authors, the readmission rate, though slowing down, remained 6% higher in 2000 than in
1991. In another study, Shapiro-Mendoza et al. (2006) obtained data of healthy appearing
LPIs born in Massachusetts from January 1, 1998 to November 30, 2002. The authors
compared LPI post delivery inpatient readmission, observational days, and mortality
(n=9552). In their first week of life, 577 (4.8%) infants were readmitted and three
quarters of these (63%) had jaundice as a principal diagnosis.
Research Question 4.What is the effect of a late preterm infant educational
intervention program on the incidence of readmission and hospital visits rate for
dehydration in the late preterm infant during the first 30 days of life? The results in
this study did not support the hypothesis that there will be a statistically significant
decrease in readmission and hospital visits rate for dehydration in the first 30 days of life
following the educational intervention. While there was a 2.9% decrease difference in
readmission rate for dehydration after the educational intervention, there were no hospital
visits documented either before or after the educational intervention.
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Previous studies show that dehydration is frequently combined with other LPI
morbidities (Meier et al., 2007; Moritz, Manole, Bogen, & Ayus, 2005). In a 5-year
retrospective study of term and near term infants, Moritz et al. (2005) assessed the
incidence of breast-feeding associated high sodium levels (>150mEq/l). The authors
found that readmitting breast-fed neonates with high sodium level frequently occurred.
However, hypernatremia is not easily identified before laboratory results; therefore
dehydration is not the initial diagnosis made. Breast-feeding associated hypernatremia
can be difficult to diagnose as most infants have other disease associated symptoms
(Moritz et al., 2005). It is therefore a possibility that LPIs in the current study may have
been treated for other co-morbidities without dehydration being documented as a
principal diagnosis. Dehydration has been associated with poor feeding especially in the
exclusively breast-feeding LPI (Meier et al., 2007). Despite documented benefits of
breast milk, breast-feeding has been associated as a risk factor for the LPI because the
LPI’s uncoordinated attempt at feeding due to immaturity becomes a contributing factor
to dehydration (Hall, Simeon, & Smith, 2000; Shaw, 2008). Contrary to current study
findings, studies by Raju et al. (2006) and Escobar et al. (2005) identified dehydration as
the second most frequent reason for readmission following birth hospitalization. This,
similar to other findings, is mostly due to feeding difficulties experienced by the LPIs.
In summary, hospital visits for hyperbilirubinemia were not statistically
significant; however there was an 8.6% decrease post intervention noted. Hospital
readmission rates for hyperbilirubinemia and dehydration were not statistically
significant though there were minimal decreased differences in the incident rates of 2.9%
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post intervention for both outcomes. There were no hospital visits for dehydration
reported before or after the intervention.
Fit with Theoretical Framework
Swanson’s (1991) caring theory was used in this study as a framework to educate
post partum and nursery nurses in the care of the LPI and their families. Swanson (1991)
defined caring as fostering a relationship with a person to whom one feels responsible
and committed. In using this model, the focus of the discussion with the nurses was
sharing the knowledge of getting to know the LPI, being emotionally present, doing
things for the LPI that they were unable to do for themselves, enabling the parents by
teaching them parenting skills, and maintaining the parents’ belief in a positive outcome
for the LPI. Swanson’s theory of caring had not been used previously to examine caring
in LPIs and their families. No previous researchers have reported nurse caring behavior in
the LPI population. However, in the current study, the model is based on the premise that
as nurses are taught to apply the concepts of knowing, being with, doing for, enabling,
and maintaining belief to the LPI population, patient outcomes will be improved.
According to Blum et al. (2010), caring can be taught and it is vital in improving patient
outcomes (Hanson, 2004). Swanson caring theory is deemed appropriate for use in this
population because it recognizes family support, participation, and choice. It is a fit
because of the family centered applicability. Applying Swanson’s concepts in an
educational intervention is viewed as a way of nurses knowing and understanding the LPI
and their families. The five concepts inform actions in nursing that are seen as
characteristics of a caring relationship (Swanson & Wojnar, 2004)
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Limitations of the Study
Limitations are uncontrolled attributes in a research study that may inhibit the
generalizability of the study findings (Munro, 2005). The current study was limited to
two settings from which participants were recruited and the use of a convenience
sampling method, thereby limiting generalization to other similar populations. The
possibility exists that nurses who are more experienced in the subject matter may have
participated in the study. The absence of a control group limits the conclusion that can be
drawn. A more rigorous study is required to minimize selection and measurement bias.
The study findings may not be representative of other maternity units; however, it is
useful in the population studied.
Another major limitation is the high attrition rate (39%), though the initial sample
size was adequate. The sample size at 1-month follow up was below the required number
to achieve statistical significance. Therefore, findings from this phase must be interpreted
with caution.
The use of the knowledge instrument may be viewed as a limitation. Although an
evidenced-based clinical practice guideline, AWHONN intended the questionnaire as an
open book test. Though the content was validated by LPI experts, the instrument has not
been previously tested and may not be sufficiently robust to adequately increase LPI
knowledge. Additionally, the second instrument, the LPI-CPS, is a self report instrument
that is inherently subject to response as well as social desirability bias (Polit & Beck,
2008). The participants may have distorted their perception of caring with the belief that
they are doing their best to provide a caring environment for the LPI and their families.
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Finally, the knowledge of the baseline data during the pretest survey may have
influenced the results of the posttest scores given the short interval between the
educational intervention and the posttest. Prior knowledge of caring theory also may have
influenced caring scores on the LPI-CPS instrument, as one of the hospital study site
already practices a caring theory philosophy.
Implications for Nursing Education and Practice
There has been an identified need to improve nursing education for the nursing
management of the LPI (AWHONN, 2010; Jorgensen, 2008b). The skill and experience
of the nursing staff influence the decisions made in caring for the LPI. According to
Medoff-Cooper et al. (2005), “Caring for the LPI requires understanding of the high risk
and specialized nursing skill, clinical vigilance and more frequent monitoring of vital
signs and other relevant clinical parameters and increased laboratory testing” (p. 668).
Well-informed nurses should be involved in partnering with parents and caregivers on the
care of the LPI. Focus should be on proper feeding to prevent associated
hyperbilirubinemia that has been identified as the number one reason for infant
readmission (Tomashek et al., 2006). Objectively grounded nursing education will dispel
the myth that views the LPI as simply another newborn. Educated parents and caregivers
are empowered to appropriately intervene for positive outcomes.
The goal of this teaching-learning intervention is to raise awareness among
nursing staff of the needs of this unique group and to discontinue the use of full term
infant policies and practice guidelines to govern late preterm infant management. Lack of
standardized specific guidelines in caring exists for the LPI. According to Jorgensen
(2008b), “LPI specific risk assessment protocol, evidenced based practice guidelines,
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discharge criteria and educational resources for families to promote standardized care and
improved outcomes for LPI need to be put in place as soon as possible” (p. 327). Nurses
must be aware of the complications associated with the LPI so that interventions are in
place as early in the pregnancy as possible. Having protocols that address issues of LPI
may ensure that all topics are discussed with parents before discharge. Dissemination of
appropriate information to infant caregivers during hospital stay and the need for proper
follow-up after discharge are important in order to achieve optimal outcomes for late
preterm infants as well as to reduce care costs.
LPI readmission after birth indicates a problem somewhere along the continuum
of care. The care of the LPI and the cost implication present many challenges for health
care providers as well as for policy makers. The LPI appropriate level of care “should be
based on medical problems apparent at birth, the potential for developing medical
problems and the ability of the nursery nurse to recognize problems and intervene in a
timely manner” (Laptook & Jackson, 2006, p. 24). Understanding morbidity risk among
LPIs will assist health care providers in anticipating and management of potential
problems associated with this group. “A comprehensive understanding of these issues by
physicians, nurses, and hospital administrators is essential to determine the resources
necessary to care for a cohort of infant in whom the risks of medical problems are often
overlooked” (Laptook & Jackson, 2006, p. 26). The goal is to achieve optimal outcomes
for infants as well as reduce hospital costs, thereby facilitating reallocation of society’s
scarce resources.
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Recommendation for Future Research
Further research studies need larger populations in order to generalize findings.
As more nursing research in this population becomes available, the level of care required
will be more evidence-based. Dissemination of such information in the obstetrical
nursing field (obstetrical journal, seminars, and conferences) will get the desired attention
and will be crucial to the proper standardized care of this population.
A recent change in the American College of Obstetrics and Gynecology
(AAP/ACOG, 2012) guidelines in the care of the pregnant woman, which mandate no
inductions or cesarean sections before 39 weeks gestation without medical necessity,
present future work in this area. Collaboration with medical staff may improve
compliance with such a guideline. The nurse patient ratio for the LPI needs adjustment
with fewer infants assigned to one nurse so that the LPIs can be cared for as infants with
specific needs. Nurses can play a major role in making changes to policies and protocols
to meet the need of the LPI. A starting point would be for nurses to recognize that the
guidelines in place for the term infant do not meet the need of the LPI (Cleaveland, 2010;
Escobar et al., 2006).
Conclusion
The literature has shown the LPI requires special attention and the need to educate
health care providers has been emphasized. The educational intervention used in this
study was effective in increasing the LPI knowledge among practicing nurses, despite the
challenges experienced. There was a drop in retention of knowledge at 1-month follow
up. There also was a 39% attrition rate noted. Therefore, caution is used in interpreting
the study results. The anticipated change in caring behavior, though not statistically
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significant, is viewed as a reinforcement of the culture of the caring behavior that is in
place already. Though the outcome measures are not statistically significant, there is a
substantial decrease in outcome especially for hospital visits for hyperbilirubinemia.
There was an 8.3% decrease following the educational intervention and practice change.
The second objective of this study was to determine the high economic cost
associated with LPI care. Given the LPI’s increased risk of mortality and morbidity,
greater attention needs to be given not only to the medical care while in hospital but also
in coordinating care with families in order to enable them to provide appropriate care
after discharge. Decreasing costs and improved quality of care is the overall goal.
According to the Institute of Medicine (2006), the overall cost of preterm birth in the
United States is estimated at $26 billion; LPIs make up 70% of the preterm birth
(Hamilton et al., 2006; Shaw, 2008).
Complications from hyperbilirubinemia and dehydration in the LPI population
can be prevented if nurses recognize the increased risk associated with their care, with
close attention to their needs (Hillman, 2007). The goal of this study was to provide
education regarding management of the LPI to nurses who, in turn, educate parents.
When parents are adequately prepared to care for the LPI, the need for additional hospital
visits and readmission is reduced. The best practice approach to solving inconsistencies
in the management of LPIs is no different than any other care issue. Evidence-based staff
education and development of standardized policies and procedures must be in place to
guide practice. Ultimately cost is reduced. Best outcomes for the LPI result in healthy
babies, fewer resources used, better prepared parents, and fewer hospital visits and
readmissions.
98
APPENDICES
99
Appendix A
AWHONN Permission
100
101
Appendix B
Swanson Permission
102
Appendix C
Late Preterm Infant Knowledge Assessment Instrument (LPI-KI)
103
104
105
106
107
Appendix D
Late Preterm Infant Caring Professional Scale (LPI-CPS)
108
Appendix E
Bhutani’s Total Serum Bilirubin Nomogram
109
110
Appendix F
Expert Assessment of the Knowledge Instrument
111
112
Appendix G
Expert Assessment of the Caring Professional Scale
113
Appendix H
PowerPoint Demonstration of Education Intervention
114
115
116
117
118
119
120
121
Appendix I
FAU IRB Approval
- 1 - Generated on IRBNet
Institutional Review BoardMailing Address:
Division of Research777 Glades Rd., SU-80, Suite 106
Boca Raton, FL 33431
FLORIDA Tel: 561.297.0777 Fax: 561.297.2573
ATLANTICUNIVERSITY http://www.fau.edu/research/researchint
Nancy Aaron Jones, Ph.D., Chair
••
•
•
•••
122
- 2 - Generated on IRBNet
123
Appendix J
Health System IRB Approval
124
125
Appendix K
CNO Letters of Approval
126
127
128
Appendix L
Recruitment Flyer
129
Appendix M
Informed Consent
130
131
132
133
Appendix N
Demographic Tool
134
135
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