* CorrespondE-mail addr

1355-1841/$ -doi:10.1016/j.

Journal of Neonatal Nursing (2010) 16, 221e228

www.elsevier.com/jneo

Neonatal nurses’ knowledge and beliefs regardingkangaroo care with preterm infants in an Irishneonatal unit

Ann Flynn a,*, Patricia Leahy-Warren b

aNeonatal Unit, Cork University Maternity Hospital, Wilton, Cork, IrelandbCatherine McAuley School of Nursing & Midwifery, Brookfield Health Sciences Complex, UniversityCollege Cork, Cork, Ireland

Available online 11 June 2010

KEYWORDSKangaroo care;Preterm infants;Mothers;Neonatal care;Knowledge;Beliefs;Research

ing author. Tel.: þ353 2ess: ann.flynn73@gmai

see front matter ª 201jnn.2010.05.008

Abstract Aim: To investigate Irish neonatal nurses’ knowledge and beliefs ofKangaroo care.Background: Although kangaroo care existed in other countries for 25 years, it isa new occurrence in Irish neonatal care. A review of the literature suggests that,while it demonstrates benefits for both infants and parents, some neonatal nursesdo not exhibit an awareness of current kangaroo care research, or hold positivebeliefs towards its use with preterm infants. As they have the most parent-infantcontact and influence over whether kangaroo care is carried out, their knowledgeand beliefs are of importance.Method: A quantitative, descriptive design with neonatal nurses (n ¼ 62) was used.Findings: Fifty six neonatal nurses (90.3%) believed kangaroo care a safe alterna-tive for stable growing preterm infants, agreeing on the benefits for both infantsand parents The overall level of neonatal nurses’ knowledge of kangaroo carevaried from good to excellent, the lowest score being 35/51. Results indicatednurses’ uncertainty regarding kangaroo care with intubated infants, and infantsrequiring blood pressure support, umbilical lines and phototherapy. This suggeststhe need to provide education on kangaroo care to foster the development of morepositive beliefs and increase staff knowledge of potential adverse effects.ª 2010 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.

1 4920514; þ353 87 0515970(mobile); fax: þ353 21 4920770.l.com (A. Flynn).

0 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.

222 A. Flynn, P. Leahy-Warren

Keypoints

This paper summarizes research that explored Irishneonatal nurse’s knowledge and beliefs regardingkangaroo care with preterm infants. A discussionon the benefits of Kangaroo care for both infantsand parents is presented. The methodology anddetails of the research questionnaire used areoutlined. Findings revealed that despite notreceiving any formal instruction in kangaroo care,the neonatal nurses in this study were moreinformed in their research-supported knowledge,as opposed to their research-supported beliefs.Irish neonatal nurses were found to have levels ofknowledge and beliefs similar to those demon-strated in previous research in countries wherekangaroo care has been in use for much longer.Recommendations for future practice include theneed for neonatal nurses to remain abreast ofcurrent research findings. Comprehensive educa-tion on kangaroo care is necessary to foster thedevelopment of more positive beliefs and ensurethat any staff knowledge deficits regardingpossible adverse effects are addressed.

Introduction & background

For small preterm infants, prolonged neonatalnursing and medical care is important for theirsurvival. However, kangaroo care is an effectivemethod tomeet infant’s equally important needs forwarmth, stimulation, parental contact and love(WHO, 2003). Kangaroo care describes the practiceof holding a preterm or low birth weight infant in anupright, prone position in skin-to-skin contactagainst their parents’ chest, dressed in a nappy, witha blanket or clothes covering the infants back(DiMenna, 2006). It occurs both in hospital and athome until at least the 40th week of correctedgestational age (Cattaneo et al., 1998). There is nodefined optimum length of time to carry outkangaroo care, although the WHO (2003) andCharpak et al. (2005) suggest 2 h ormore. If correctlyapplied, kangaroo care can be safely used for stablelow birth weight infants at any level of care(Cattaneo et al., 1998; Charpak and Figueroa, 2001).

There are many documented physiological andemotional benefits of kangaroo care for infantsand their parents. Kangaroo care offers immediateand long term benefits for infants such asincreased physiological stability (Bergman et al.,2004; Ludington-Hoe et al., 2004; Sontheimeret al., 2004), improved brain growth and deve-lopment (Tessier et al., 2003; Rojas et al., 2003),and increased sleep and improved behavioural

outcomes (Ohgi et al., 2002; Ludington-Hoe et al.,2006). While there appears to be agreement in theresearch regarding the positive effects of kangaroocare on thermoregulation, oxygenation andbehavioral states in preterm infants, there areconflicting results in the literature for its effec-tiveness with infants less than 28 weeks correctedgestational age, weighing <1000 g, or ventilated,in terms of their energy expenditure, heart rate,respiratory rate, oxygen saturation, growth andlength of stay (Bauer et al., 1998; Bohnhorst et al.,2001; Charpak et al., 2001). Overall, the researchadvises practitioners wishing to carry out kangaroocare to proceed with caution in preterm infantswho are under 1000 g, on mechanical ventilation,less than 28 weeks corrected gestational age orless than one week after birth.

Some studies have been inconclusive in demon-strating more favourable outcomes when comparinginfants receiving kangaroo care to infants receivingtraditional care, but no study has demonstratedadverse effects to parents or infant (Chwo et al.,2002; Conde-Agudelo et al., 2003; Anderson et al.,2003a; Miles et al., 2005; DiMenna, 2006). Parentsalso appear to benefit from kangaroo care withincreased parent-infant interaction and emotionalbonding (Tessier et al., 1998; Feldman et al., 2002;Gale Roller, 2005; Tallandini and Scalembra, 2006),enhanced and more prolonged duration of breast-feeding (Anderson et al., 2003a; Rojas et al., 2003),and increased parental satisfaction rates (Carfootet al., 2005). Kangaroo care is believed tostrengthen the connection between infant andparent, with each becoming more sensitive to eachother (Tessier et al., 1998; Anderson et al., 2003a).Although parents value the kangaroo care experi-ence, they need attention and assistance fromneonatal nurses to alleviate any of their anxieties,enhance the development of their parental role andmodify the neonatal environment to optimize thekangaroo care experience for infant and parent.

The use of kangaroo care with preterm infantshas been demonstrated to shorten the length ofstay in hospital (Charpak et al., 1997; Tessieret al., 1998) and be professionally satisfying forneonatal nurses (Chia et al., 2006). It is also clearthat healthcare professionals positively or nega-tively affect parental practice of kangaroo care.Some healthcare professionals question whetherkangaroo care is beneficial, express concern thatkangaroo care may be a burden on mothers, orconsider the practice unnecessary or even unsafe(Anderson et al., 2003b). One quarter to one thirdof all respondents in research by Franck et al.(2002) listed staff nurses or doctors as not sup-porting parental holding, with 17% stating that

Neonatal nurses’ knowledge and beliefs 223

nurse or doctor concerns limited parental holding.These concerns include cardio-respiratory insta-bility, accidental extubation or dislodgement ofarterial or umbilical lines during kangaroo care,and these findings were supported by similarresearch in Australia and France (Engler et al.,2002; Chia et al., 2006; Mallet et al., 2007).Other healthcare professionals view kangaroo careas the optimal environment for adaptation ofmother and infant following a preterm birth(Kirsten et al., 2001; Anderson et al., 2003a).

Recent research pertaining to neonatal nurses’knowledge and beliefs of kangaroo care indicatesthat, while neonatal nurses may be aware of theresearch literature available on kangaroo care,their own personal knowledge and beliefs influ-ence their encouragement or discouragement ofkangaroo care with preterm infants as an evidencebased practice (Engler et al., 2002; Melnyk et al.,2004; Chia et al., 2006; Mallet et al., 2007;Frasure, 2008). While kangaroo care has been inuse for up to twenty-five years in some countries(Charpak et al., 2005), it is relatively new to Irishneonatal care. Nonetheless, individual nurses havea responsibility for the quality of their practice,and how they develop their practice further(McCormack and McCance, 2006). The growingacceptance of evidence-based practice indicatesthat nurses need to become better informed intheir clinical area (Jennings and Loan, 2001). Whilethe research evidence demonstrates the benefitsof kangaroo care for infants, parents, staff and thehealthcare organisation, its use in everydayneonatal nursing care is not widespread (Francket al., 2002), particularly in Ireland. Therefore,the purpose of this research was to examine thelevel of research evidence based knowledge andbeliefs neonatal nurses in an Irish regionalneonatal unit held regarding the use of kangaroocare with preterm infants.

Methodology

The aim of the research was to examine the levelof neonatal nurses’ knowledge and beliefsregarding the use of kangaroo care for preterminfants, therefore a quantitative, descriptivedesign on a convenience sample of 62 neonatalnurses was used. Eighty-seven neonatal nursesworking in a 37-bedded regional Level III neonatalunit were invited to participate, as neonatalnurses have the most infant-parent contact (Neu,1999), are in an optimal position to closelymonitor infants (Brown and Timmins, 2005) and arein a position to either advocate or discourage the

use of kangaroo care in the neonatal unit (Chiaet al., 2006). The nursing staff in this unit wasa combination of the recent amalgamation ofthree distinctly separate neonatal units, andcomprised of midwives, paediatric nurses, andgeneral nurses with intensive care nursing experi-ence. Some staff had an additional neonatalnursing qualification. For convenience and clarity,they were collectively referred to as neonatalnurses.

Instrument

The questionnaire used was a 47-item instrumentthat had been modified from an original ques-tionnaire used by Engler et al. (2002). The originalquestionnaire had 108 items, divided into fivesections, beliefs, knowledge, barriers, unit profileand respondent demographics. Due to time andresource restraints only the beliefs and knowledgesections of the original kangaroo care question-naire were utilised for the Irish study as these weredetermined by Estabrooks et al. (2003), Melnyket al. (2004), and Frasure (2008) to have themost influence on research utilisation by nurses.The revised questionnaire consisted of Likert-typescale questions regarding participants beliefs ofkangaroo care and 17 true-false statementsregarding kangaroo care knowledge, as well asbrief demographic section seeking characteristicsof the respondents such as age, basic and highestlevel of nursing education, present work status andprimary role within the neonatal unit.

A reliability coefficient of 0.80 is considered thelowest acceptable value for a well-developedmeasurement instrument (Burns and Grove, 2005).Engler et al. (2002) described their personalbeliefs scale as receiving a Cronbach’s Alpha reli-ability coefficient of 0.88 and the knowledge scaleas receiving a Cronbach’s Alpha reliability coeffi-cient of 0.84. This supports a claim of reasonableinternal consistency for the two scales used in thequestionnaire. A Cronbach’s Alpha reliabilitycoefficient was conducted on the modified ques-tionnaire using SPSS, and a value of 0.81 wasobtained, supporting the reliability of the ques-tionnaire previously described by Engler et al.(2002). A pilot study of five participants from theintended sample of neonatal nurses was conductedto check the face validity and comprehensibility ofthe questionnaire for participants, and no changeswere made to the format of the questionnairebased on the results of the pilot study. Theresearch was reviewed and approved by theUniversity Ethics Committee of the maternityhospital where the research was carried out.

224 A. Flynn, P. Leahy-Warren

Procedure

The data was collected by means of a 47-itemquestionnaire previously developed by Engleret al. (2002). A one-month data collection periodwas used as many neonatal staff worked reducedhours. All neonatal nurses received a letter ofinvitation to participate in the study. Staff whoconsented to participate then received the ques-tionnaire, each containing an identificationnumber, which corresponded to a master list ofstaff names held by the researchers. The identifi-cation number on the questionnaire was to assistwith the coding of respondents responses. Eachquestionnaire had a pre-addressed envelope, toensure confidentiality of responses. A clearlymarked box was at the main nurses’ station in theneonatal unit for receipt of completed question-naires in their sealed envelopes.

Analysis

Descriptive statistics were chosen to describe whatneonatal nurses’ personal knowledge and beliefsare regarding kangaroo care with preterm infants.Likert scales were used in the questionnaire todetermine the opinions of respondents. Descrip-tive statistics were analysed and includedfrequency, percentages and measures of centraltendency such as the mean and the mode. Datawas analysed using SPSS computer softwarepackage (SPSS, 2006).

Results

Sample characteristics

Seventy neonatal nurses in the unit (80.4%)received a questionnaire, and overall 71.3%(n ¼ 62) returned the completed questionnairefor analysis. All the neonatal nurses were

female, ranging in age from 24 to 60 years ofage. 50% (n ¼ 31) had an additional neonatalqualification and 45.2% (n ¼ 28) had achievednursing qualifications to university higherdiploma level.

Knowledge

Fifty-six neonatal nurses (90.3%) believedkangaroo care a safe alternative for stable growingpreterm infants, agreeing on the benefits for bothinfants and parents.

When questioned whether kangaroo care iscontraindicated in infants less than 28 weeksgestation, 85.5% of neonatal nurses (n ¼ 53)correctly indicated that this was false. Fiftyneonatal nurses (80.6%) were correct thatneither is kangaroo care contraindicated ininfants <1000 g. Improved breathing pattern anddecreased apnoeas during kangaroo care wasidentified by the majority of neonatal nurses(90.3%, n ¼ 56). Almost all (96.8%, n ¼ 60)correctly indicated that infants do not havemore bradycardias, and 95.2% (n ¼ 59) accu-rately identified that most infants do not havea decrease in temperature, during kangaroocare.

Despite answering some questions in theknowledge section incorrectly, when the responseswere given a score, the overall level of neonatalnurses’ knowledge in relation to kangaroo carevaried from good to excellent.

Only 17.7% of neonatal nurses (n ¼ 11) correctlyidentified that infants on vasopressors should nothave kangaroo care, while 77.4%, (n ¼ 48)correctly identified that infants on phototherapytreatment can participate in kangaroo care.

Forty-nine neonatal nurses (79%) correctlyidentified that the transfer to the parental chestwas the most stressful part of kangaroo care for

Neonatal nurses’ knowledge and beliefs 225

the preterm infant. Thirty two neonatal nurses(51.6%) indicated that they did not know that therate of accidental extubation was no higher duringkangaroo care than during traditional care. Addi-tionally, 46.8% of respondents (n ¼ 29) indicatedthat the need for pharmacological blood pressuresupport (vasopressors) did not prohibit the use ofkangaroo care in these infants.

These findings demonstrate that, despite therelatively short time since 2003 that kangaroo carewas first informally introduced into the threeoriginal neonatal units prior to their amalgam-ation, the neonatal nurses surveyed have a goodknowledge of its beneficial effects, but still are notfully informed regarding some preterm infantssuitability to participate.

BeliefsThe beliefs section of the kangaroo care ques-tionnaire contained 25 statements regardingkangaroo care with preterm infants. The responsesto 13 of these statements were evidence basedand were utilised to give a score that indicated thestrength of the neonatal nurses’ beliefs. Theneonatal nurses in this study indicated that theyhad strong to very strong positive beliefs regardingkangaroo care as demonstrated in the scores ach-ieved by 63% and 23% of neonatal nurses respec-tively. An overwhelming majority of neonatalnurses (98.4%) indicated that kangaroo carebenefits preterm infants. Forty-nine neonatalnurses (79%) considered that infants should beallowed to participate regardless of gestationalage, while 71% indicated that infants should beallowed to participate regardless of weight.

Neonatal nurses also agreed that kangaroo careincreased parental confidence, and 80.6% agreedthat kangaroo care should be offered to all parentsin the neonatal unit. Sixty neonatal nurses in thisstudy (96.8%) believed that the nurse-parentteamwork required for kangaroo care was worththe effort and 70.9% indicated that they lookforward to introducing it to parents. The majorityof neonatal nurses, 79% (n ¼ 49), agreed that allpreterm infants should be allowed to participate inkangaroo care regardless of gestational age. Therewas also strong support for infants to receivekangaroo care regardless of weight, with 71% ofneonatal nurses (n ¼ 44) agreeing or stronglyagreeing Despite the positive response to kangaroocare regardless of the infants gestation andweight, 58% of neonatal nurses (n ¼ 36) agreed orstrongly agreed that kangaroo care was notfeasible with some patients. Forty-six neonatalnurses (74.2%) believed that intubated infantsshould be allowed participate in kangaroo care.

When presented with the statement that infantswith umbilical lines should not be allowedkangaroo care, 17.7% (n ¼ 11) agreed or stronglyagreed.

Discussion

According to Fulbrook (2003, p.98), “the essenceof nursing is in human caring, and the focus ofnursing care is on meeting the needs of individualpatients”. Results indicated nurses’ uncertaintyregarding kangaroo care with intubated infants,and infants requiring blood pressure support,umbilical lines and phototherapy. All of the abovefindings indicated that despite research to supportthe use of kangaroo care for a variety of preterminfants, there still exists some concerns on thesuitability and safety of some preterm infants toparticipate in kangaroo care. The fear of acci-dental extubation, or arterial or venous linedislodgement appear to be commonly heldmisconceptions by both healthcare professionalsand parents as previously identified by Engler et al.(2002), Franck et al. (2002) and Chia et al. (2006),as they are not grounded in empirical evidence.The WHO practical guidelines on kangaroo care(2003) emphasise that the preterm infant must beclassified as stable prior to receiving kangaroocare, and an infant requiring pharmacologicalsupport to maintain blood pressure cannot beconsidered stable. It is this lack of clearly definedcriteria for suitability for kangaroo care thatappears to contribute to the lack of clarity overthe appropriateness of kangaroo care for somepreterm infants.

Neonatal nurses agreed on the benefits ofkangaroo care in promoting bonding, a findingsupported by Nirmala et al. (2006). Forty-nineneonatal nurses (79%) correctly identified that thetransfer to the parental chest was the moststressful part of kangaroo care for the preterminfant. compared with only 7% of respondents inthe original study by Engler et al. (2002). Although80.6% of neonatal nurses (n ¼ 50) agreed thatkangaroo care would improve an infants’ outcome,58% agreed that kangaroo care was not feasiblewith some patients. This issue ties in with fearsabout infant suitability previously identified in theknowledge section. These findings are in keepingwith other studies on beliefs towards kangaroocare (Engler et al., 2002; Franck et al., 2002; Chiaet al., 2006; Mallet et al., 2007). Indeed, Chiaet al. (2006) and Engler et al. (2002) indentifiedthat neonatal nurses’ beliefs about kangaroo careare more positive in units where it is practiced.

226 A. Flynn, P. Leahy-Warren

This may account for over 80% of neonatal nursesdisagreeing with the statements that kangaroocare interrupts caregiving, keeps nurses too tied tothe bedside, interferes with completion of tasks,modern NICU’s are not a suitable place forkangaroo care and that the increased preparationtime is not worth the benefits.

Because of these fears, some authors (Ludington-Hoe et al., 2003; WHO, 2003; Chia et al., 2006)advocate guidelines that specify the precautionsneeded to ensure infants remain stable and to avoidinconsistent practices. Theneed for a kangaroo careprotocol is strongly recommended by the WorldHealth Organization (2003) who state that everyhealth facility that implements kangaroo careshould develop a written policy and guidelines thatincorporate clear criteria for selection, monitoringand evaluation.

Nurses need to find ways to integrate currentresearch findings into practice (Glacken andChaney, 2004). Engler et al. (2002) suggested thatneonatal nurses needed educational assistance thatemphasised the knowledge and skills needed toprovide kangaroo care safely and effectively.According to Higgs et al. (2001, p4) “professionalpractice without underpinning theory is guess-work”. No educational program can be effectiveunless the participants’ beliefs regarding kangaroocare are taken into account (Leh, 2007). By identi-fying staff preconceptions and misconceptionsregarding kangaroo care with preterm infants,a change can be brought about in negative beliefs orattitudes towards kangaroo care (Leh, 2007).

Although most of the neonatal nurses aresupportive of kangaroo care, none of the respon-dents in this Irish study had received any formaltraining or education in kangaroo care. Thiscompares with the respondents in the Chia et al.(2006), where 52.9% had received supervisedinstruction in kangaroo care techniques and 35.3%had participated in a continuing education programabout kangaroo care. DiMenna (2006) believed thatincreased knowledge of, and education on,kangaroo care for healthcare providers should leadto increased routine use of it as a beneficial inter-vention. In the research by Chia et al. (2006) andMallet et al. (2007) respondents viewed staffeducation as essential in providing them with theknowledge and skill to facilitate kangaroo care andgive accurate and supportive information toparents. McCleary and Brown (2003) furtherenhance this belief with their own theory thatindividual nurses’ research knowledgemaynot beasimportant as the process by which organisationsimplement research in the workplace. Chia et al.(2006) suggested that educational programs on

kangaroo care should include skill development,physiological monitoring of infant, and transfertechniques, as this is the most stressful part ofkangaroo care for the infant. Chia et al. (2006) alsosuggested that neonatal nurses should get theopportunity for supervised practice, which corre-lates with Melnyk et al. (2004).

Yet, promoting kangaroo care is not withoutpractical problems. Despite the benefits that uti-lising kangaroo care protocols and guidelines, onemust remain aware of the limitations of policyimplementation. It may not be possible to achievefully holistic and family centred neonatal care asthe infants’ clinical condition or staff availabilitymay dictate when kangaroo care can be initiated.Yet, health professionals’ support initiating andcontinuing kangaroo care with parents is vital(Neu, 1999; Franck et al., 2002; Engler et al., 2002,and Chia et al., 2006). Kangaroo care can assistinfants and parents adapt to premature delivery,and enhance the neurodevelopmental future ofthe preterm infant while in the neonatal unit.Using kangaroo care, nurses can facilitateinvolvement of the parents in as many opportuni-ties as possible to come to know and care for theirinfant, particularly during long hospitalizations inthe neonatal unit.

Conclusion

The aim and objectives of this study were toexamine neonatal nurses’ knowledge and beliefsregarding kangaroo care in the neonatal unit. Thiswas achieved by employing a quantative descrip-tive research design. Data collection took placeover a one month period and sixty-two neonatalnurses participated in this study by completinga questionnaire. A positive finding was that 90.3%of the neonatal nurses in this sample supportedkangaroo care and demonstrated a good level ofrelevant research knowledge. It is evident fromthis study that some disagreement persists overthe suitability of kangaroo care for certain sub-groups of preterm infants. These include intubatedinfants, infants with umbilical or arterial lines andlow birth weight infants. However, the neonatalnurses in this study had more research-supportedknowledge as opposed to beliefs. This study indi-cates the need to implement strategies to over-come such constraints.

Recommendations for clinical practice

� Comprehensive education based on up to dateresearch evidence detailing the benefits and

Neonatal nurses’ knowledge and beliefs 227

risks of kangaroo care could be incorporatedinto new staff induction, and continuingeducation days for neonatal and midwiferystaff. This will facilitate the development ofpositive beliefs towards kangaroo care.

� Interactive workshops may increase nurses’knowledge, skills and confidence in the initia-tion of safe and effective kangaroo care withpreterm infants. These should support theneonatal nurse to educate and communicatethe benefits of kangaroo care to all parents andother healthcare professionals within theneonatal environment.

� Organisational support is also needed tofinance continuing education and to developpractice guidelines and protocols, to ensurethe standardisation of information for parentsand staff.

� Incorporating interdisciplinary and multi-disci-plinary team approaches would augment theimplementation of kangaroo care into everydaypractice. This in turn can facilitate parents,infants and staff to have a positive kangaroocare experience.

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