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The newborn behavioral observations system as a nursing intervention to enhance engagement in first-time mothers: feasibility and desirability.

The birth of a first child is a time of enormous change, instability, and uncertainty in a woman's life. Indeed, it is a developmental transition when the mother's task is the attainment of the maternal role (Beeghly et al., 1995; Boland, 2002; Brazelton & Nugent, 1995; Nelson, 2003; Nugent & Blanchard, 2005). Successful completion of this task is crucial to the well being of the mother, and ultimately the infant, as ineffective maternal role transition, poor attachment and unsuccessful bonding have been linked to abandonment, developmental delays, and failure to thrive syndrome (Leitch, 1999; Lowdermilk & Perry, 2000; Nelson, 2003; Kennell & Klauss, 1998; Rubin, 1967; Schenk, Kelley, & Schenk, 2005). Transition to the maternal role requires that mothers be engaged with their infants so that bonding and attachment can occur (Brazelton & Nugent, 1995; Gaoulet et al., 1998; Kennell & Klauss, 1998; Nelson, 2003; Schenk, Kelley, & Schenk, 2005) (see Figure 1).

[FIGURE 1 OMITTED]

Studies have shown that by orienting new mothers to the unique behavioral characteristics of their infants, the central activities of engagement can be fostered, and barriers to maternal role transition can be overcome (Brazelton Institute, n.d.; Golas & Parks, 1986; Lydic & Nugent, 1982). It has been suggested that the postpartum period is a "teaching moment par excellence" for new families, a time when families are primed to be engaged with their infants, and a time when bonding is heightened (Blanchard, Kerzner, & Nugent, 2005; Kennell & Klauss, 1998; Nugent & Blanchard, 2005). Therefore nurses, as the primary caregivers in the immediate postpartum period, are in a perfect position to initiate interventions to enhance the activities of engagement that are so important to maternal role transition. The purpose of this study was to assess the feasibility and desirability of the Newborn Behavioral Observations (NBO) system as a nursing intervention to foster maternal engagement during the first days of life in the inpatient setting.

Review of the Literature

In a meta-synthesis of qualitative studies on the transition to motherhood, Nelson identified engagement as the basic social process of maternal role transition (2003). The central activities of engagement identified were, experiencing the presence of the infant by the mother, the mother's active participation in care, and maternal commitment. Bonding is the mother's coming to know, love, and accept the new infant, and is defined as an enduring relationship between parent and child that is unique, positive, and specific to the particular child and occurs through the process of attachment (Bowlby, 1969; Harrison, Sherrod, Dunn, & Oliver, 1991; Hewitt, Bihum, & Goldsmith, n.d.; Kennell & Klauss, 1998). Goulet and colleagues (1998) identified three attributes as central to attachment: proximity, reciprocity and maternal commitment. Upon comparison, engagement emerges as a process through which attachment and bonding are fostered. Experiencing the infant requires the proximity of attachment, active participation occurs through the reciprocal behaviors of the mother and infant, and maternal commitment is central to both engagement and attachment. Therefore engagement is not only the basic social process of maternal role transition, but is also linked inexorably to the important processes of attachment and bonding (see Figure 2).

[FIGURE 2 OMITTED]

One of the barriers faced in the transition to motherhood can be infant temperament. Infants who are perceived as ill-tempered and hard to care for, or who exhibit those characteristics due to a lack of effective maternal responsiveness to their behavioral cues, can be susceptible to negative parent-child interactions and impairment of maternal bonding (Barnard, n.d.; Hewitt, et al., n.d.; Pokorni, 1996; Porter & Hsu, 2003; Widmayer & Field, 1981). This can be overcome by helping mothers both better understand the challenges which their infants' temperaments may present and discover the stimuli and comfort measures that elicit their infants' best responses (Brazelton & Nugent, 1995). In this way, the mother's understanding of the infant is increased and any feelings of guilt that the infant's "bad" behaviors are due to poor caregiving are allayed (Gibes, 1981; Golas & Parks, 1986).

Over 30 years ago, Brazelton recognized that newborns are not passive recipients of their care, but instead possess a rich array of abilities to express needs and elicit parental responses even in the immediate postpartum period (Brazelton & Nugent, 1995). Infant behaviors express attempts, failures, and successes at self-regulation, stress, and social readiness (Brazelton & Nugent, 1995; Blanchard et al., 2005). The Neonatal Behavioral Assessment Scale (NBAS), introduced by Brazelton in 1973 (Brazelton & Nugent, 1995), has proven to be a means by which to understand the complexities of the newborn in a variety of populations and has been shown to be an effective neurobehavioral assessment tool and aid in the early prediction of later child temperament and developmental problems (Als, Tronick, Lester, & Brazelton, 1979; Brazelton & Nugent, 1995; Gibes, 1981; Ohgi et al., 2003). Additionally, since its development, the NBAS has been increasingly recognized as an effective clinical tool for nursing assessment, planning, and intervention (Brazelton Institute, n.d.; Buckner, 1983; Gibes, 1981; Harrison, et al., 1991; Kennell & Klauss, 1998; Lydic & Nugent, 1982; Nugent, 1981; Widmayer & Field, 1981).

Based on over 25 years of experience with the NBAS, Nugent, Keefer, O'Brien, Johnson, and Blanchard (in press) developed the NBO as a more flexible clinical intervention tool to promote positive parent-infant relationships that could be more easily incorporated into routine care (Brazelton Institute, n.d.; J.K. Nugent, personal communication, March 3, 2006). The NBO is designed to orient parents to the characteristics and competencies of their newborns by assessing, with them, their infant's responses to a variety of neurobehavioral assessment items (Blanchard et al., 2005; Northern Lights, 2003). Throughout an NBO session, the clinician encourages parents to explore the knowledge they already posses about their infants and make predictions and observations (Northern Lights, 2003). This shared exploration of the infants' responses guides the examiner in providing anticipatory guidance for caregiving. In initial trials, the NBO was rated by pediatric professionals (n=222), and parents (n=31) as good or excellent in helping parents learn about their infants and in fostering interest; however more research is needed (Nugent & Blanchard, 2005; Blanchard et al., 2005).

Methodology

The investigator completed training in the administration and use of the NBO at The Brazelton Institute and obtained Institutional Review Board (IRB) approval for this study. Participant confidentiality was protected throughout the study by eliminating identifying data on any paperwork. A convenience sample of first-time mothers was recruited from the mother/baby unit at a large university hospital. The participants were limited to first-time mothers, over age 19, who were rooming-in with their healthy term infants. Informed consent was obtained, demographic data were collected, and an NBO session was conducted by the investigator with each mother and infant.

After each NBO session, the investigator conducted an interview with the mother to elicit her perceptions of the intervention. The interview questions measured the mother's opinions of the effectiveness of the NBO to enhance activities that would increase engagement. The interview consisted of open-ended questions as well as closed-ended questions that mothers scored on a Likert-type scale. Higher ratings indicated a more positive opinion of the intervention. The interview questions were reviewed for content validity by three experts. The questionnaire had a Cronbach alpha of 0.96 when the questions concerning barriers to participation and level of enjoyment were excluded from analysis.

After the NBO session and interview, mothers completed a Newborn Behavioral Observations (NBO) Parent Questionnaire developed by the Brazelton Institute. The purpose of the questionnaire was to further assess the usefulness of the NBO in teaching parents and enhancing engagement. The NBO questionnaire is a Likert-type scale that rates items on a 4-point scale.

After the NBO session, the investigator also rated the mother's participation during the intervention. The Maternal Participation Scoring tool was used in the study to rate maternal behaviors during the NBO sessions and to assess its usefulness for triangulating data. The Maternal Participation Scoring Tool is a 3 point Likert-type scale. A higher rating reflected greater participation in the demonstration. Content validity was reviewed by three experts. Interrater reliability was established between the investigator and an experienced clinician at 100%. The Maternal Participation tool had a Cronbach alpha of 0.73 when the item regarding whether mothers related the baby's behavior to previous knowledge was excluded from analysis.

After completion of the mothers' segment of the study, the investigator gave presentations to mother/baby unit nurses at two staff meetings. The presentations included the conceptual and theoretical basis of the study, and results of the mothers' interviews, questionnaires, and participation scoring. The nurses then completed questionnaires on the feasibility and desirability of using the NBO on their unit.

Results

Sample. Sample characteristics of the mothers (n=10) included six African Americans, two Caucasians, one Asian, and one Indian participant. Four were single, two were living with a partner, and four were married. Participants ranged in age from 19 to 27. The most frequent income range was $15000 to $18000 (n=3), with one under $15000, two from $18001 to $20000, and two in the $25001 to $30000 range. Two did not indicate an income range. Six participants reported greater than a high school education. Four of the participants had attended prenatal classes. No demographic data were collected from the sample of mother/baby unit nurses (n=20).

Feasibility. Feasibility issues of particular interest were cost, barriers, and length of time to administer. The costs of a one-day training for professionals break down as follows: $200 for professionals in training, residents, and fellows; $400 for physicians; and $300 for nurses and allied professionals. On-site group training is also available for 25-30 participants at a cost of $10,000.

No significant barriers to implementing the NBO as an intervention in the postpartum period were identified by the investigator or the mothers who participated. The NBO sessions lasted between 20 and 30 minutes with an average length of 25 minutes. Sessions were occasionally interrupted or delayed due to other activities.

When nurses (n=20) were asked if they could include an NBO session in their routine patient care, 7 said yes, 6 said no, and 7 were unsure. Nurses were split on who should perform the NBO sessions between the choices of the mother's nurse (n=5), the infant's nurse (n=8), and a specialist (n=11). Some chose more than one option.

Desirability. The mothers' responses to the quantitative interview questions are presented in Table 1. Minimum and maximum scores, means, and standard deviations are reported for each question. Items were rated on a 4-point scale from 1 (nothing) to 4 (a lot).

The mothers' perceptions of the effectiveness of the NBO as reported on the NBO Parent Questionnaire are listed in Table 2. Minimum and maximum scores, means, and standard deviations are reported for each. Items were rated on a 4-point scale from 1 (nothing) to 4 (a lot).

The mothers' participation in the intervention was rated to determine if any correlation existed between the observed level of participation and the mothers' reported effectiveness of the NBO in increasing engagement activities. The investigator rated eight maternal behaviors, indicating maternal interest in the activities, on a 3-point scale from 1 (nothing) to 3 (a lot). The Pearson correlation coefficient between the mean scores of the closed-ended interview questions and the Maternal Participation tool was statistically significant (r=0.66, P<0.05).

Qualitative data elicited from the mothers were analyzed using constant comparative analysis to identify themes. Mothers were asked what they liked about the intervention, what they learned about their infants, and how it could help them in caregiving. Analysis of the qualitative data revealed three main themes. Mothers reported that the intervention was useful; that it encouraged them to experience their infant; and that it taught them ways to actively participate in caregiving. Table 3 lists participant responses under each theme.

Nurses (n=20) reported that there was a need among their patient population for interventions that help parents learn about their infants, with 3 indicating a need in some or most patients and the remainder, 17,

indicating a need in all patients. Most nurses (n=18) recognized a need for interventions that enhance engagement in all patients, the remainder saw a need in some or most. The nurses thought that the NBO would help parents learn about their infants (n=20), and enhance maternal engagement (n=20). When asked if they thought their patient population would benefit from the NBO, 75% of nurses (n=15) said all or most would, the others were either unsure (n=1) or believed some patients would (n=3).

Those nurses who gave qualitative responses indicated that they thought the NBO would benefit their patients by increasing their knowledge and understanding of their infants, decreasing fear, encouraging learning about development, and increasing bonding and confidence. Some respondents indicated specific populations that would benefit, such as first-time mothers, high parity mothers, young mothers, or those with low socioeconomic status.

Discussion

Nurses are in a prime position to support and implement interventions that enhance engagement of first-time mothers in the postpartum period. Interventions such as the NBO that help mothers learn to recognize, understand, and respond to the behavioral cues of their infants could be used by unit nurses or nurse specialists either with all mothers or with those identified as being at risk for ineffective maternal role transition. This study suggests that there is a need among mothers for measures that increase their understanding of their infants and that the NBO could be an effective nursing intervention in enhancing engagement, encouraging maternal role transition, and promoting attachment and bonding.

Nurses who participated in this study overwhelmingly identified a need among their patient populations for interventions that enhance engagement and help mothers learn about their infants and unanimously believed the NBO would be effective in doing so. There were few barriers identified by participants or the investigator. Because some of the nurses in this study thought that their current patient load might prohibit their routine use of the NBO, it might be most cost and time efficient to have one or more nurses specializing in patient education and newborn assessment conduct NBO sessions with all families or those identified as high risk.

Mothers rated the NBO high for its efficacy in increasing their knowledge of their infants and how to respond to and interact with them. Participants also rated the NBO high as an overall learning experience. Qualitative data revealed strong support for the usefulness of the NBO and its ability to enhance engagement activities. A significant finding was that two of the components of engagement, experiencing the infant and active participation in care, emerged as benefits of the intervention.

The results of this study suggest that the NBO could be a desirable and efficacious intervention to enhance engagement in first-time mothers. The primary limitations to the application of the results of this study to the larger population were the use of a small convenience sample and screening criteria that limited the inclusion of data from a larger, more diverse population. Future studies should target a larger sample of first-time mothers. Research should also target a large heterogeneous sample to identify situations in which the NBO would be most beneficial, and then focus studies on specific groups of mothers identified as being at increased risk for ineffective role transition, such as adolescents, mothers of premature infants, single mothers, those who lack support, and those with limited resources. Additionally, to add to the body of knowledge on culturally competent care, studies should be conducted to determine if the NBO could successfully be used with mothers from various cultures.

Acknowledgments: The author would like to express a special word of thanks to her family, Dr. Kevin Nugent, Dr. Lynda Harrison, Ashley Wood, Dr. Jill Ross, Jennifer Kelley, unit nurses and participants for their support and encouragement. The investigator also acknowledges the UAB School of Nursing Honors Fund for partial reimbursement of expenses.

Section Editor's Note: In the next issue of Pediatric Nursing, the "Family Matters" section will begin a six-part series addressing parental roles in the health care setting. This important series will comprise first-person accounts of parents who have served as advocates for their own children, run parent-to-parent support groups, served on hospital committees, and contributed in other ways to making health care more family-centered. Read this series and envision new possibilities for parent partnerships in your health care setting.

The Family Matters section focuses on issues, information, and strategies relevant to working with families of pediatric patients. To suggest topics, obtain author guidelines, or to submit queries or manuscripts, contact Elizabeth Ahmann, ScD, RN; Section Editor; Pediatric Nursing: East Holly Avenue Box 56; Pitman, NJ 08071-0056; (856) 256-2300 or FAX (856) 256-2345.

References

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Barnard, K.E. (n.d.). The role of parent-child interactions in development: Perspectives from temperament, attachment, high-risk, and cross-cultural research. Retrieved July 20, 2005, from http://www.isisweb.org/ICIS2000Program/ web_pages/group555.html

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Leslie Wesley Sanders, BSN, RN, is a Recent Graduate, University of Alabama at Birmingham, School of Nursing, Birmingham, AL. She is currently employed in Neonatal Nursing at UAB. This work was done as part of her senior honors project.

Ellen B. Buckner, BSN, MSN, DSN, is Associate Professor and Coordinator of Honors in Nursing, University of Alabama at Birmingham, School of Nursing, Birmingham, AL.
Table 1. Interview Questionnaire Results

               N=10                  Minimum   Maximum   Mean    SD

Did you enjoy the NBO session?         3.0       4.0     3.4    0.52

Did it encourage you to discover
  more about your baby?                3.0       4.0     3.6    0.52

Did it increase your knowledge
  of your baby's behavior?             1.0       4.0     3.2    1.03

Did it increase your understanding
  of your baby's behavior?             2.0       4.0     3.1    0.74

Did it reinforce what you had
  already learned?                     2.0       4.0     3.1    0.74

Did it help you learn how to meet
  your baby's needs?                   2.0       4.0     3.0    0.82

Table 2. NBO Parent Questionnaire Results

               N=10                   Minimum   Maximum   Mean    SD

How much did you learn about

...what your baby can do?               3.00      4.00    3.70   0.48

...how your baby can communicate?       2.00      4.00    3.50   0.85

...how you can respond?                 3.00      4.00    3.50   0.71

...how you can help when your baby
   is crying?                           3.00      4.00    3.60   0.52

...how to interact with your baby?      2.00      4.00    3.80   0.63

...how baby can regulate sleep?         3.00      4.00    3.50   0.53

Overall how much would you say the
NBO helped you

...feel closer to your baby?            3.00      4.00    3.10   0.57

...feel more confident as a parent?     3.00      4.00    3.60   0.52

...get to know more about your
   baby?                                2.00      4.00    3.50   0.71

...communicate with or relate to
   the person conducting the NBO?       3.00      4.00    3.70   0.48

Overall how would you rate the NBO
as a learning experience?               3.00      4.00    3.70   0.48

Table 3. Themes Identified as Benefits of the NBO By Mothers

Usefulness of the NBO             Experiencing the Infant

"I enjoyed it ... it would be     "Watching [the baby]."
good for other moms."

"The session was useful."         "Learning about [the baby]."

"Everything was useful."          "Interacting with [the baby]."

"The NBO is good and useful."     "Techniques for monitoring
                                  different behavioral items."

"The person conducting ... gave   "Learning about [the baby's]
useful suggestions."              temperament."

"I liked it a lot."               "Learning about [the baby's]
                                  strength."

"I learned a lot."                "Learning about [the baby's]
                                  abilities."

Usefulness of the NBO             Active Participation in Care

"I enjoyed it ... it would be     "Introduced to some new techniques
good for other moms."             for baby care."

"The session was useful."         "I will pay attention to what [the
                                  baby] is trying to tell me."
"Everything was useful."          "Soothing techniques."

"The NBO is good and useful."     "Paying attention to cues and how
                                  noise affects her."

"The person conducting ... gave   "Responses to noisy environment."
useful suggestions."

"I liked it a lot."               "Tummy time."

"I learned a lot."                "Feeding before [the baby] cries."
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Author:Sanders, Leslie Wesley; Buckner, Ellen B.
Publication:Pediatric Nursing
Article Type:Report
Geographic Code:1USA
Date:Sep 1, 2006
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