Changes in Maternal Competence,
Responsiveness and Stress with
Implementation of NICU-PLAY for
Very Preterm Infants in the NICU
Jacqueline M. McGrath, PhD, RN, FNAP, FAAN
RK Elswick, PhD, Heidi Fidler, BS, RN,
Susan Vollum, BS, RN, Sara Wagner, BS, RN
Improving Outcomes for
Ashlee Noorthoek, MS, BS, RN,
Preterm Infants and Families
funded by a Presidential Award from Virginia Commonwealth University
1
in conjunction with the School of Nursing, Richmond, VA
Why do we care?
23 weeks gestation
40 weeks gestation
Benefits of Touch and Massage
Touch
• First sense to develop
• Skin sends messages to the
brain even when sleeping
• Release of hormones
• Infant Attachment
• Kinds of touch
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Improved weight gain
Enhanced neurological development
Decreased length of stay
Improved feeding/digestion
Increased active sleep and less REM
sleep
• Improved glucose metabolism
• Parental social interaction
Touch and Massage
Infant Massage
Preterm Infant Massage
• Flows from head to toes
• Involves soft and nonmechanical touch
• Begins with gentle
stroking
• Begins with one
extremity, fingers or
toes and progresses to
more body involvement
as tolerated
• Field, Diego & Hernandez
• White-Traut et al.
Maternal Participation in Massage
Parent-Participative
Loving Gentle Infant Massage
Age Appropriate Touch
Your Cue-Based Assessment
Synactive
Theory of
Development
Cue-Based
Protocol Driven
Intervention
EMPOWER
Education
Program
NICU-PLAY
Loving Touch
and Massage
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Short-term Infant Outcomes
Pre-Existing Risk Factors
1. Hospital Progression
2. Neuromotor Development
Infant Characteristics
Gestational Age, Gender,
Ethnicity,
Birth Weight, Acuity of Illness,
Stress, Neurodevelopment
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Maternal Characteristics
Maternal Age, Ethnicity,
Acuity of Illness,
Socio-Economic Status,
Depression, Anxiety, Stress
NICU- PLAY
Parent-Participative
Loving Gentle Massage
Exploratory Aim
Age Appropriate
Your Cue-Based
Assessment
Potential Biologic Mechanisms
of Growth and Neurodevelopment
1. Cortisol
2. Insulin-like Growth Factors
Maternal Preterm Competence
1. Recognition/sensitivity to infant behavioral cues
2. Competence in preterm infant care
3. Infant temperament, vulnerability and
overprotection
4. Mother Infant Interaction
Birth
NICU-PLAY begins at 3 days of
age through NICU discharge
Transition to
Home
46 wks PMA
6wks CA
Figure 1. Conceptual Model: How NICU-PLAY affects Outcomes (Birth to 6 wks CA).
PURPOSE & STUDY DESIGN
• Determine the feasibility of the
experimental protocol.
• Examine maternal stress during
implementation of a mother-participative
massage intervention for very preterm
infants beginning in the first week of life
and continued until infant discharge.
• A prospective single-arm design
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Sample Characteristics
• Very preterm infants between 25-30 weeks gestation
• 19 enrolled
16 completed most aspects of protocol
– 1 infant passed away
– 1 infant withdrew for maternal complications
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• 5 Caucasian
• 12 male
11 African American
4 female
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M = 1205 gms. (SD = 313 gms.)
M = 28 wks. 5 days (SD = 12 days)
M = 4.67 (SD = 2.50)
M = 6.83 (SD = 1.47)
M = 20.79 (SD = 14.99)
M= 25.47 yrs. (SD = 5.9 yrs.)
Birth Weight
Gestational Age
APGARS 1 minute
APGARS 5 minute
SNAPPE – II scores
Maternal Age
Measurement of Maternal Outcomes
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Competence
Wellbeing
Stress
Satisfaction
Depression
Skill
Maternal-Child Interaction
INTERVENTION PROTOCOL:
• Infants received PLAY protocol minimum of three
times each week beginning by 7 days of age
(preferably by 3 days of age), all delivered by mothers
• Dose --- Age specific & Physiologic & Behavioral
Cue-Based -- A decision-tree for monitoring the
infants’ responses that has been tested in other
research was used for implementation decisions related
to administration of the intervention.
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Phase I – toes, feet, legs -- 26-27 weeks PMA
Phase II – fingers, hands arms – 28-29 weeks PMA
Phase III – Abdomen, back – 30-31 weeks PMA
Phase IV – Face 32+ weeks PMA
• Infants do not progress beyond the phase appropriate
for their gestational age and if older will progress only
one phase each day they are on the PLAY protocol.
RESULTS
• Maternal Responsiveness measured with MIRI –
mothers became more responsive over the course of the
protocol
Mean at enrollment
Mean at discharge
Mean at follow-up
84.13, SD = 13.33
93.92, SD = 9.51
99.71, SD = 8.88
• Mothers were more confident in care of the infant ICQ
scores increased over course of intervention
Mean at enrollment
Mean at discharge
Mean at follow-up
71.80, SD = 13.79
75.91, SD = 11.39
85.14, SD = 4.45
• Parent Sense of Competence (PSOC) also increased
over the course of the intervention (not as meaning full change)
Mean at enrollment
Mean at discharge
Mean at follow-up
3.65, SD = 0.44
3.66, SD = 0.50
3.70, SD = 0.40
RESULTS
• Infant cues recognition also increased as
measured with the RIBBS Engagement tool
(White-Traut et al.)
Mean at enrollment
Mean at discharge
Mean at follow-up
7.73, SD = 1.28
7.83, SD = 1.12
8.17, SD = 1.33
• Mother’s sense of child’s vulnerability decreased
over the course of the protocol.
Mean at discharge
Mean at follow-up
38.69, SD = 5.15
36.91, SD = 5.94
• Mother’s sense of the infant’s temperament did
not change over time.
Mean at discharge
Mean at follow-up
1.96, SD = 0.30
2.01, SD = 0.31
RESULTS
Maternal Stress measured with PSS-NICU
(Parent Stressor Scale)
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Phase 1
Phase 2
Phase 3
Phase 4
Discharge
RESULTS
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Maternal stress WAS decreased significantly over
the course of study as compared to results from
other studies where PSS-NICU has been used.
Although it would seem the result would decrease
over time as the infant becomes more stable;
participation decreased stress right from the start.
Our participants also became increasingly involved
in caregiving and were able to provide care and
NICU-PLAY with less assistance as comfort with
their infants increased.
They also visited more than other mothers and were
more likely to be actively involved with caregiving.
CONCLUSIONS
• No significant negative responses to the PLAY
protocol
• Mothers found the intervention helpful and fun for
them
• Connecting mothers to the program is easy to do
but further refinement is needed.
• Physiologic parameters remained within normal
limits through-out the protocol
IMPLICATIONS
for further Research
• PLAY Protocol was well received by
parents and staff in the NICU
• Finding of this study support further
research on developmentally
appropriate multi-sensory massage in
preterm infants
Research is FUN!!
QUESTIONS??