Challenges in Nursing Education and Research
© 2020 by Taylor & Francis Group, London, ISBN 978-1-003-04397-3
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Challenges in Nursing Education and Research
Stressful behaviour in infants can be demonstrated by stretching the toes and hands, crying, and changing skin colour (Rustina, 2015). Stress in premature babies has a large impact, both short and long term. The response of premature infants is often not visible in their behaviour, but it greatly influences their neurological development (Wilson & Hockenberry, 2012). Environmental conditions in the NICU that create stress can cause disruption in neurosensory and behavioural development that resulted in the risk of visual impairment, motor development, cognitive decline, and emotional disturbance (Kenner, Altimier, & Boykova, 2020).
Many other effects of stress on infants, especially in premature babies that can interfere with various baby’s body systems such as neurological, respiration, sensory, balance, and other systems, thus minimizing the risk of interference through non-pharmacological interventions must be done (Hadian & Sabet, 2013). Non- pharmacological interventions to reduce comfort in infants include implementing developmental care (minimizing lighting, reducing noise, nesting and positioning, minimal handling), swaddling, kangaroo care, breastfeeding, and family-centred care (Lista et al., 2013; Walter-Nicolet, Annequin, Biran, Mitanchez, & Tourniaire, 2010).
Other actions to overcome breathing problems while comfort considering the babies are doing suctioned by the “four hands” technique.
This “four-handed” technique for mucus suctioning aims to create comfort, reduce stress, and improve the baby’s self-regulation behaviour and facilitate the work of nurses in suctioning mucus. Comfort is one of the basic needs that must be met to improve health and productivity. This technique was introduced by Cone, Pickler, Grap, Mcgrath, and Wiley (2013) through a Cone dissertation (2011). Four- handed or four-handed technique is the implementation of mucus suctioning carried out by two people, namely the operator and assistant. The operator will focus on the mucus suctioning done, while the assistant will assist the implementation of mucus suctioning such as maintaining the position of the endotracheal tube (ET) tube to stay in position, as well as creating comfort for the baby such as positioning the arms and legs flexing if needed.
The implementation of mucus suctioning by these two people has been studied in various places and has become a recommendation and guide in several hospitals. Therefore, it is important to conduct research on the implementation of four-handed mucus suctioning techniques to create comfort in low birth weight babies.
This study aimed to identify the effect of four-handed method in suctioning procedure on the neonates’ comfort whom hospitalized in an intensive care unit.
II. METHODS
This study was conducted in Neonatal Intensive Care Unit (NICU) ward at one of Indonesia national hospital for one month in 2016.
Four-Handed Method Improves Neonates’ Comfort During Suctioning
Study Design
This study design was quasi-experimental, divided into two groups (control and intervention) with a pre-test and post-test approach.
Technique of Sampling
Purposive sampling technique was used to choose 20 low birth weight neonates.
Premature infants 28–36 weeks of gestational age with ventilators or CPAPs and suction performed were the sample criteria in this study. Babies who met these criteria were then determined including the control group or the intervention group. Controls (n = 10) received routine technique while the intervention group (n = 10) received four-handed suctioning technique.
Ethical Considerations
The ethical study was conducted by the Research Ethics Committee of the Nursing Faculty at the Universitas Indonesia.
Data Collection and Analysis
In both groups, control and intervention, measurements of oxygen saturation, heart rate and comfort scores were performed. Assessment of oxygen saturation and heart rate noted by reading the values listed on the patient monitor three times at 3 minutes before the suction procedure, the fifth second after inserted suction tube, and 5 minutes after the procedure was finished. The comfort score scores using a Paediatric Comfort Assessment tool (PCA) developed by Intermountain Healthcare (2007) based on Kolcaba’s Behavioural Comfort theory consisting of vocal responses, signs motor movements, general appearance, face, and other signs such as mental state, communication, awakening, and changes in breathing. PCA scores were approved through the video recording by the researcher. Scores greater than 4 for each assessment item indicate discomfort, so the higher score obtained, then the baby feels stressed and uncomfortable (Intermountain Healthcare, 2007).
Both groups performed suction procedures to clear the airway. Mucus suctioning in the control group were carried out according to hospital standards while paying attention to the sterility of the action. The suctioning procedure in the intervention group was carried out by two nurses with different activities.
The first nurse focused on mucus suction and ensured that the action remain sterile, the second nurse holding the endotracheal tube tube in position if needed and provided comfort position such as reflecting the baby’s hands and feet with a gentle touch.
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Figure 13.1 Hand - Position During Four-Handed Suctioning
Gestational age, correction age, oxygen saturation, heart rate, and well-being/comfort score were noted for both groups. Data analysis was conducted using independent T-test by computer program.
III. RESULTS
The result showed that the implementation of the four-handed suctioning increases the comfort level of the neonates during suctioning. This was proved from the stability of the oxygen saturation as well as the increasing score of well-being. The results describe on the table 1 and chart 1–3.
Table 13.1 Distribution of Respondents by Gestational and Correction Age (N=20)
Age Groups N Mean SD
Gestational Intervention 10 32.9 2.13
Control 10 32.7 2.11
Correction Intervention 10 33.6 1.83
Control 10 34.1 1.72
Figure 13.2 Mean Oxygen Saturation in Four-Handed and Standard Suctioning
The oxygen saturation was significantly higher in the intervention group compared to the control group (p = 0.038).
Four-Handed Method Improves Neonates’ Comfort During Suctioning
Figure 13.3 Mean Heart Rate in Four-Handed and Standard Suctioning
No significant differences were found on neonatal heart rate (p=0.096) and the PCA score was higher significantly in the intervention group (p=0.001).
IV. DISCUSSION
Premature infants in the Neonatal Intensive Care Unit (NICU) can experience discomfort caused by changes in environmental conditions that are very different between inside and outside the womb such as noise level, lighting, temperature, and actions that manipulate the baby (Kenner et al., 2020). Babies in the womb only hear sounds with low intensity such as the sound of the mother’s heartbeat, while when treated in an intensive room there are various sounds with high intensity including the sound of an alarm monitor, incubator, ventilator, and syringe pump. The content with minimal lighting is very different from the external conditions of the womb, which is a brightly lit NICU room. Other conditions that make a baby stressed and uncomfortable are both invasive and non-invasive actions that cause pain and interrupt the baby’s rest such as the implementation of a mucus suction procedure (Barbosa, Cardoso, Brasil,
& Scochi, 2011).
On the other hand, babies cannot express their discomfort through verbal sentences as they do in adults. In addition, in the intensive care room, parents or other families are not always in the nursery, so nurses play an important role in detecting the discomfort. Assessment of discomfort includes the assessment of physical, psychospiritual, socio-cultural, and environmental discomfort (Apóstolo
& Kolcaba, 2009; Kolcaba, 1995; Kolcaba, Tilton, & Drouin, 2006). In this study, the assessment of comfort scores using the Pediatric Comfort Scale (PCA) which is the adoption of Kolcaba comfort theory consisting of vocalizations (calm/awake, grimacing, and crying), signs of motor movements (calm, relaxed muscles, agitation, and anxiety), appearance (like touch, try to be interesting, anxious movements/
pulls, face (smile, calm expression, and fear), and others (mental focus, to unusual breathing) (Intermountain Healthcare, 2007).
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In this study, suction was carried out by two nurses with good cooperation.
Gentle touch is highly recommended when performing procedures on premature babies (Pepino & Mezzacappa, 2014). The touch given by the assistant procedure nurse to the baby by positioning the baby’s arms and legs flexed and holding the baby’s head gently, can provide comfort to the baby. In addition, before touching the baby, the assistant procedure nurse warms his hands first to prevent cold stress.
Premature babies under 36 weeks’ risk of developing hypothermia (Forsythe Saleski
& Allen Jackson, 2013). Therefore, when the baby is in a comfortable condition, then suctioning mucus, the baby’s stress level is not at a high score.
The implementation of the four-handed technique also aims to reduce work stress on nurses. Nurses who work in intensive rooms are more at risk of experiencing stress at work and need support (Bayuo & Agbenorku, 2018). With the implementation of mucus suctioning by two people, the risk of error is also reduced (Cone et al, 2013). Therefore, the implementation of this technique becomes the standard procedure for implementing mucus suctioning in several hospitals, one of which is in China.
In addition to comfort scores, other physical responses were also assessed in this study. The physical response in the form of changes in heart rate and oxygen saturation is one of the baby’s responses to actions such as mucus suctioning. If both of these values are stable it indicates that the action can be well tolerated. In addition to physical responses, another response is the stress response that can be seen is blood cortisol levels which are also synchronous with cortisol levels in saliva (Calixto, Martinez, Jorge, Moreira, & Martinelli, 2002).
Breathing often occurs in infants with a gestational age of less than 37 weeks. Committee on Fetus and Newborn (2003 in Weiss & Tolomeo, 2012) states that significant apnea in infants is stopping breathing for more than 20 seconds or more than 10 seconds accompanied by bradycardia or desaturation
<80–85%. Apnea of prematurity occurs in more than 50% of premature babies and the majority in infants weighing less than 1000 grams (Alden et al., 1972 in Weiss & Tolomeo, 2012).
Heart rate is one indicator of discomfort in infants. In this study, the heart rates of the two groups differed, but not significantly. This can occur because of heart control when pain occurs, according to the research of Waxman, Riddell, Tablon, Schmidt, and Pinhasov (2016) which states that heart rate can increase by 5–10 bpm in invasive procedures. Premature infants with gestational age of 28–32 weeks who performed stabbing procedures with a heel stick there was a significant increase in heart rate with an average increase in heart rate of 22.4 bpm with a standard deviation of 15.42. Infants with gestational age have a significant increase in heart rate in invasive procedures from birth to one month after birth in line with the increased role of parasympathetic nerves in controlling heart rate.
Four-Handed Method Improves Neonates’ Comfort During Suctioning
V. CONCLUSION
Implementation of mucus suction using the four hands method can increase comfort for the baby during the procedure. This can be seen from the presence of stable oxygen saturation values and vocalization responses, motor movements, faces, and general appearance. therefore, the implementation of this method is highly recommended for its implementation on the NICU space layout.
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Challenges in Nursing Education and Research
© 2020 by Taylor & Francis Group, London, ISBN 978-1-003-04397-3