|Ahead of print
|Transitional care program for enhancing competence of primary care givers in home care management of neonatal intensive care unit graduates
Mumtaj Gangihal1, K Kavitha2, Satish Rathod1, Laxmi Pujari1, Laxmi Swami1, Amar Pyati1, Basheerahamed J Sikandar3
1 Final Year B.Sc Nursing Student, BLDEA's Shri BM Patil Institute of Nursing Sciences, Vijayapura, Karnataka, India
2 Professor & Head, Departments of Child Health Nursing, BLDEA's Shri BM Patil Institute of Nursing Sciences, Vijayapura, Karnataka, India
3 Professor, Department of Medical Surgical Nursing, BLDEA's Shri BM Patil Institute of Nursing Sciences, Vijayapura, Karnataka, India
Click here for correspondence address and email
|Date of Submission||19-Oct-2020|
|Date of Decision||08-Nov-2021|
|Date of Acceptance||22-Dec-2021|
|Date of Web Publication||12-Jan-2022|
The discharge of a newborn who had been admitted in neonatal intensive care unit (NICU) for weeks or months after birth is both joy and worry for parents. A comprehensive plan is needed to prepare the parents so that they can take care of their baby by their own after discharge from NICU. The objective of the study was to assess the effectiveness of transitional care programmes on the competence of primary caregivers in home care management of NICU graduates. A Quasi-experimental design with a quantitative approach was adopted. The sample consisted of 80 primary caregivers selected by purposive sampling technique. Data were collected using the demographic profile, structured knowledge questionnaire and observation checklist. The findings showed that the mean knowledge score of mothers regarding home care of NICU graduates improved from 12.8 ± 3.93 in pretest to 27.55 ± 1.93 after the transitional care programme. There was a significant difference between pretest and posttest knowledge of mothers in the experimental group (P < 0.001). The mean knowledge score of caregivers regarding homecare of NICU graduates improved from 12.7 ± 2.47 to 25.6 ± 3.25 after the transitional care programme. However, no significant difference was observed between the study participants of experimental and control groups (P > 0.05). A randomised control trial with a large sample size is needed to find out the impact of transitional care programmes. This intervention can be incorporated into the discharge plan of NICU graduates to minimise the readmission to the hospital.
Keywords: Care provider, competency, home care, intensive care unit, newborn, transitional care
|How to cite this URL:|
Gangihal M, Kavitha K, Rathod S, Pujari L, Swami L, Pyati A, Sikandar BJ. Transitional care program for enhancing competence of primary care givers in home care management of neonatal intensive care unit graduates. Indian J Cont Nsg Edn [Epub ahead of print] [cited 2022 Dec 6]. Available from: https://www.ijcne.org/preprintarticle.asp?id=335678
| Introduction|| |
Every year around 4 million newborns die globally. The mortality rate of high-risk newborns after discharge from the hospital is found to be 22.3/1000 for extremely low-birth weight infants and high mortality rate is noted in very low-birth weight infants.
Due to bed shortage and poor socio-economic status often these tiny babies are discharged early from the neonatal intensive care unit (NICU). Home discharge policies for NICU graduates vary from one setting to another and very little data are available on optimal timing for discharging. Many a times, they require readmission due to inadequate or poor post-discharge care.
Most often high-risk neonates are discharged from the NICU with unresolved health care issues, on-going technology needs and require close monitoring of nutritional status, growth, medication administration and early recognition of any illness or infections at home.,
In such situations, the parents may not have adequate knowledge and skill in caring for these delicate babies. To alleviate these problems and help them to gain confidence and competence in home care, a proper discharge plan is needed. Study findings have thrown light on the importance of health education, village health teams and social support in enhancing parents' abilities of home care. Parent and family-centred Interventions were found to be very effective in the promotion of newborn's wellbeing and development.
Adequate time for preparation of the family to provide care to these babies in their own environment and getting community resources for adequate support is necessary before discharge. Making home visits by a nurse can be the best means of transitional care of NICU graduates. Further, anticipating the challenges faced by mothers and the significant family members who directly involved in the care of high-risk newborns, there is a need for a comprehensive interventional strategy which focuses on assessment, education, demonstration and monitoring of newborn care before and after discharge from NICU. In countries like India, most often, grandmothers will be the caregivers of the newborn who directly involved in the care of newborns. Hence, this study was conducted to assess the Effectiveness of Transition Care Programme on Competence of Primary Caregivers in Home Care Management of NICU graduates at Selected Hospitals, Vijayapur, Karnataka, India.
| Methodology|| |
Quasi-experimental pretest–posttest design with quantitative approach was adapted. The research design chosen for the present study lacks the property of randomisation but has other two characteristics of experimental design, i.e., manipulation (transition care programme) and control (standard care). However, matching was done to ensure homogeneity between the two groups.
The data were collected from two tertiary level hospitals for paediatric care in Vijayapur, Karnataka (one for the experimental group and another for control). The settings were chosen based on feasibility. The setting where the researchers are working/studying is taken for the experimental group and the other is taken as the control group. The study was conducted between 1 March, 2019 and 31 August, 2019.
The sample size was 80 (20 mothers and 20 significant family members each in both experimental and control groups) selected by non-probability purposive sampling technique. Mothers of ill newborns discharged from NICU and the primary caregivers who were being with the ill newborns in both hospital and home settings were included in the study. The sample size was calculated based on the average number of NICU admission per month, i.e., 90–100 (population size), with a confidence interval of 95% and a margin error of 5%.
- Study group:
Primary caregivers: 20
- Control group:
- Mothers: 20
- Primary caregivers: 20
The total sample size required for the study was (20 × 4) 80.
Tools and techniques
Pro forma for collecting baseline information of primary care givers. It consisted of 3 parts: (a) Mother's profile (14 items), (b) Newborn profile (7 items) and (c) primary caregiver profile (5 items).
Structured knowledge questionnaire was used to assess the knowledge of primary caregivers regarding home care management of NICU Graduates. The tool consisted of 30 items related to the care of NICU graduates in home. The questions were organised under five domains, namely breastfeeding (9 items), bathing/massage (6 items), genital care (2 items), medication administration (5 items), infection prevention (4 items) and thermoregulation (4 items). The correct responses were given 1 mark and incorrect response 0. Hence, the total score was 30. The data regarding knowledge was collected using structured interview schedule (read aloud method). The respondents were asked to tell the answer from the options listed.
Observational checklist for assessing the practice of primary care givers regarding home care management of NICU graduates. This tool consisted of 2 parts: (a) Assessment of practice of mothers (14 items) (b) Assessment of practice of caregivers (9 items). The respondents' practice was assessed by direct observation in the hospital as well as the home setting during the home visit. The items of observation included techniques of breastfeeding and burping, hand hygiene, thermoregulation of newborns, oil massage and medication administration. The research team members were trained by the guide for observation technique using checklist before the onset of data collection. If the particular step was correctly carried out then the score was one, if it is not done, then the score was 0.
- Ethical clearance certificate was obtained from the Institutional ethical committee of BLDEA's Shri BM Patil Institute of Nursing Sciences, Vijayapur (Ref. no. 318/1/2019-20, dated 19 January, 2019)
- Informed consent was taken from all participants at the time of sample recruitment.
Tools were administered to the study participants of both experimental and control groups to assess baseline characteristics, knowledge and skills in caring for high-risk newborns transferred from NICU to ward. Transitional care programme was implemented for the experimental group which involved three aspects: (1) family-centred health education using appropriate audiovisual aids. (2) Demonstration of procedures such as medication administration (oral), burping technique and oil massage. (3) A guide sheet was prepared in Kannada for DO's and Don'ts in home care of NICU graduates and given to the caregivers. The intervention was given after the transfer of babies from NICU to postnatal ward and before discharge from the hospital. The investigators visited the homes on the 1st day and 7th day of discharge of NICU graduates. The 1st day visit was intended to monitor, assess and assist the caregivers in transitional care. No data were collected during this period as it was part of the interventional bundle. Routine discharge teaching was given for the control group by health-care providers. Post-test was administered to assess the competence of primary caregivers of both groups regarding home care management of NICU graduates after 7 days of discharge. The data were collected during the second home visit on the 7th day.
| Results|| |
The data obtained were analysed using descriptive and inferential statistics on the basis of objectives and hypotheses of the study. SPSS (version. 20, SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp) was used to analyse the data.
The statistical tests were selected based on the normality of the distribution of sample data. The non-parametric tests such as Wilcoxon signed-rank test (for within-group comparison) which is equivalent of paired t-test and Mann–Whitney test (for between group comparison) which is equivalent of unpaired t-test were used to find out the effectiveness of transitional care programme on the competence of primary caregivers regarding home care management of NICU graduates. Chi-square test was used to find the homogeneity and association of demographic variables with the knowledge of mothers.
Findings revealed that the majority of mothers (65%) in the experimental group were in the age group of 25–35 years. Whereas the same percentage of control group mothers were in the age group of 20–25 years.
Most of the participants in both groups, i.e., 95% and 85% respectively were Hindus. Majority of the mothers in both groups (40% and 50%, respectively) have completed preuniversity level of education. Majority of mothers in both groups (85% and 80% respectively) were homemakers. There was a significant difference between the two groups related to the place of residence at 0.05 level of significance (χ2 = 8.580; P = 0.0354). Majority of mothers in both groups (60% and 65%, respectively) had no prior information about the care of newborns (postnatal) in the antenatal period [Table 1].
|Table 1: Frequency, percentage and homogeneity comparison of baseline characteristics of mothers|
Click here to view
The average weight of newborns at birth was 2.13 ± 0.79, 2.09 ± 0.79 in experimental and control groups, respectively. Regarding the duration of NICU stay, the average days of stay in NICU were 14.7 ± 7.83 days in the experimental group and 15.63 ± 10.18 days in the control group.
The average weight of newborns at the time of discharge was 2.19 ± 0.59 kg and 2.23 S ± 0.61 kg, respectively. The most common reason for admission of newborns to NICU was Low-birth weight in both groups, followed by meconium aspiration and respiratory distress syndrome [Figure 1]. None of the newborns was discharged with special devices like nasogastric tubes etc.[Table 2].
|Figure 1: Frequency distribution about reason for the admission of newborn to neonatal intensive care unit|
Click here to view
|Table 2: Baseline characteristics of neonatal intensive care unit graduates|
Click here to view
All the caregivers in both groups in the study were grandmothers of NICU graduates. The average age of caregivers was 51.65 ± 7.44 years in the experimental group, whereas 48.25 ± 6.19 years in the control group and majority of them were uneducated.
Wilcoxon signed-rank test was used to compare within-group difference of knowledge score of mothers and caregivers of experimental group before and after transitional care programme intervention. The differences between the pre-test and post-test scores were not normally distributed. Hence, this test was chosen. The findings showed that there was a significant difference between pre-test and post-test knowledge scores of mothers (change in percentage: 53.53%%, P < 0.001) as well as caregivers (change in percentage: 50.39%, P < 0.0001) [Table 3].
|Table 3: Within group comparison of knowledge of mothers and caregivers regarding home care management of neonatal intensive care unit graduates|
Click here to view
However, Mann–Whitney U-test for comparison between the groups showed that there is no significant difference between the mothers of experimental and control groups [Table 4] as well as caregivers [Table 5] at P > 0.05. The control group which received the regular discharge teaching also had significant improvement in knowledge.
|Table 4: Between groups comparison of knowledge of mothers regarding home care management of neonatal intensive care unit graduates before and after the transitional care programme|
Click here to view
|Table 5: Between groups comparison of knowledge of caregivers regarding home care management of neonatal intensive care unit graduates before and after the transitional care programme|
Click here to view
Regarding within-group comparison of the practice of experimental group mothers and caregivers on the care of NICU graduates, the Wilcoxon's matched pair test showed a statistical difference in their practice score before and after intervention (P < 0.001 and P < 0.0001, respectively) [Table 6].
|Table 6: Within group comparison of practice of mothers and caregivers regarding home care management of neonatal intensive care unit graduates in experimental group|
Click here to view
However, there are no significant differences observed in scores of experimental and control groups mothers and caregivers (P > 0.05) [Table 7] and [Table 8]. This finding again reveals that in control group also the practice scores improved considerably.
|Table 7: Between groups comparison of practice of mothers regarding home care management of neonatal intensive care unit graduates|
Click here to view
|Table 8: Comparison of practice of caregivers regarding home care management of neonatal intensive care unit graduates|
Click here to view
Chi-square test for association between knowledge and practice of mothers and caregivers divulged that only the age of the mother in the experimental group had a significant association with the knowledge scores (P < 0.05).
| Discussion|| |
In the present study, the average knowledge score of experimental group mothers regarding home care of high-risk newborns had increased from 12.8 ± 3.93 at pre-test to 27.55 ± 1.93 during post-test. Further, the practice score of the experimental group participants had shown significant enhancement on within-group comparison at P < 0.001 and P < 0.0001, respectively, for mothers and caregivers. It indicates that the transitional care programme has an impact on the competency of primary caregivers regarding homecare of NICU graduates. However, there was no statistical difference noticed in knowledge and practice of mothers and caregivers between experimental and control groups (P > 0.05). It might be due to the routine discharge health education given for the control group is equally effective. Small sample size could contribute to the study result. Nasir et al. reported that mothercraft classes were effective in enhancing knowledge and newborn care practices of mothers. Although there was no significant difference between the transitional care programme that was provided by the researcher and the regular discharge teaching, any innovative methods can enhance the way the information is delivered to people.
The knowledge scores were low at pre-test for both mothers and caregivers in this study. Evidence from literature also suggests that there is a lack of knowledge about home care in mothers and caregivers at discharge. Abu-Shaheen et al. noted that the proportion of mothers with knowledge of at least three danger signs of the newborn was very low. Singh et al. also reported that 48.7% of the mothers had inadequate knowledge and 33.8% had unsatisfactory practice regarding care of newborn. Similar findings were observed in the study by Bansal et al. that majority (68%) of the mothers had average knowledge and 20% had poor knowledge regarding essential newborn care. There is no significant association found between knowledge of mothers with their demographic variables at 0.05 level of significance (Χ2 = 7.179; P = 0.028) except for maternal age. In contradiction to present findings, Gul et al. found a significant association between family income, maternal education and the practices on newborn care. However, a study by Berhea et al. found that the newborn care practice had a positive association with mother's education.
The findings of the study could not be generalised as the sample size was small owing to the short period of data collection.
| Conclusion|| |
The nurses who are working in the NICU setup need to update knowledge for effective and advanced care and to improve the outcome of the patients. The health-care personnel and nurses, in particular, have to extend their hands for a better outcome by adapting the better discharge plan for care givers of babies and visiting homes for assessing the practice of mothers and caregivers. Policy and procedures in NICU discharge planning can include transitional care programme. Randomised clinical trials with large sample size or multi-centre trials can be conducted to assess the effectiveness of transitional care programme. The developmental outcome of high-risk newborn can be assessed post-discharge.
Financial support and sponsorship
This project was funded by Rajiv Gandhi University of Health Sciences, Bengaluru.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jehan I, Harris H, Salat S, Zeb A, Mobeen N, Pasha O, et al
. Neonatal mortality, risk factors and causes: A prospective population-based cohort study in urban Pakistan. Bull World Health Organ 2009;87:130-8.
De Jesus LC, Pappas A, Shankaran S, Kendrick D, Das A, Higgins RD, et al
. Risk factors for post-neonatal intensive care unit discharge mortality among extremely low birth weight infants. J Pediatr 2012;161:70-4.e1-2.
Abdallah Y, Namiiro F, Nankunda J, Mugalu J, Vaucher Y. Mortality among very low birth weight infants after hospital discharge in a low resource setting. BMC Pediatr 2018;18:239.
McCormick MC, Shapiro S, Starfield BH. Rehospitalization in the first year of life for high-risk survivors. Pediatrics 1980;66:991-9.
Nabiwemba EL, Atuyambe L, Criel B, Kolsteren P, Orach CG. Recognition and home care of low birth weight neonates: A qualitative study of knowledge, beliefs and practices of mothers in Iganga-Mayuge Health and Demographic Surveillance Site, Uganda. BMC Public Health 2014;14:546.
Prabhakaran H. Enhancing maternal knowledge in improving life of low birth weight babies. IOSR J Nurs Health Sci IOSR-JNHS 2015;4:71-7.
Mutch L, Newdick M, Lodwick A, Chalmers L. The contribution of low birth weight to infant mortality and childhood morbidity. N Engl J Med 1985;312:82-90.
Purdy IB, Craig JW, Zeanah P. NICU discharge planning and beyond: Recommendations for parent psychosocial support. J Perinatol 2015;35 Suppl 1:S24-8.
Nasir NM, Amran Y, Nakamura Y. Changing knowledge and practices of mothers on newborn care through mother class: An intervention study in Indonesia. J Trop Pediatr 2017;63:440-6.
Abu-Shaheen A, AlFayyad I, Riaz M, Nofal A, AlMatary A, Khan A, et al
. Mothers' and caregivers' knowledge and experience of neonatal danger signs: A cross-sectional survey in Saudi Arabia. Biomed Res Int 2019;2019:1750240.
Singh DR, Harvey CM, Bohara P, Nath D, Singh S, Szabo S, et al
. Factors associated with newborn care knowledge and practices in the upper Himalayas. PLoS One 2019;14:e0222582.
Bansal P, James MM. A descriptive study to assess the knowledge of postnatal mothers regarding essential newborn care in a selected health center, Badarpur in Delhi. Int J Nurs Midwif Res 2016;3:1-5.
Gul S, Khalil R, Yousafzai MT, Shoukat F. Newborn care knowledge and practices among mothers attending pediatric outpatient clinic of a hospital in Karachi, Pakistan. Int J Health Sci (Qassim) 2014;8:167-75.
Berhea TA, Belachew AB, Abreha GF. Knowledge and practice of essential newborn care among postnatal mothers in Mekelle City, North Ethiopia: A population-based survey. PLoS One 2018;13:e0202542.
Department of Child Health Nursing, BLDEA's Shri BM Patil Institute of Nursing Sciences, Vijayapura, Karnataka
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
| Article Access Statistics|
| Viewed||618 |
| PDF Downloaded||20 |