Theoretical framework

skintoskincontact_FWarticle.pdf

Home >Nursing homework help >Theoretical framework

EMPIRICAL STUDIES

Skin-to-skin care for dying preterm newborns and their parents – a phenomenological study from the perspective of NICU nurses

Ingjerd G. Kymre RN, Pediatric Nurse (PN), MA, PhD (Student)1 and Terese Bondas RN, PHN, MNSc, LicNSc, PhD(Professor)2

1 PHS, Center for Practical Knowledge, University of Nordland/UiN, Bodø, Norway and

2 Institute of Nursing and Health, University of

Nordland, Bodø, Norway

Scand J Caring Sci; 2013; 27: 669–676

Skin-to-skin care for dying preterm newborns and

their parents – a phenomenological study from the

perspective of NICU nurses

Background: Consequences of separation between preterm

newborns and their parents have been discussed in many

aspects, thus skin-to-skin care (SSC) has become com-

mon practice in Scandinavian Neonatal Intensive Care

Units (NICUs) since the 1980s. The International work-

shop on Kangaroo Mother Care (KMC), 2009, recom-

mends implementation of continuous KMC as the gold

standard pervading all medical and nursing care, based

on empirical studies and clinical guidelines and they sug-

gest that KMC may be used during terminal care in

agreement with parents. Parents have a strong desire to

be near their child and give support and emotional com-

fort when the condition of the child requires it, and it

has been suggested that medical staff expect parents to

be with the neonates, and therefore, encourages them to

hold the neonate while it is dying. The practice of SSC at

the end of life has been under-researched, however.

Aim: The aim of this study, which is part of a larger

study on neonatal nursing care, was to describe the phe-

nomenon of how nurses enact SSC for dying preterm

newborns and their parents.

Design: A phenomenological reflective life world design.

Setting and participants: A purposive sample of 18 nurses

from three Scandinavian NICUs.

Findings: The essential meaning of the phenomenon was

expressed as strong belief in the urgency of SSC in pro-

viding mutual proximity and comfort for dying preterm

newborns and their parents. The nurses act upon this

belief and upon an engagement in securing the best pos-

sible present and future experiences of being close, in

which the SSC is understood as a necessary premise in

achieving the intended optimal conditions. The findings

are elaborated in relation to previous caring and nursing

research and phenomenology.

Conclusions: Skin-to-skin care for dying preterm newborns

and their parents is the preferred caring practice among

Scandinavian NICU nurses who consider it of major

importance to facilitate proximity and comfort through

SSC when the newborn is still alive. The authors suggest

this practical knowledge from NICU nurses perspective to

be acknowledged in discussions concerning end-of-life

care for preterm newborns and their parents and we rec-

ommend more formal establishment of this practice. Fur-

ther research is needed on parents’ experiences of skin-to

skin caring in this vulnerable end of life situation of

‘being with’ their dying newborn.

Keywords: Skin-to-skin care, end-of-life care, neonatal

nursing, dying preterm newborns, mutual experience,

proximity in dying, phenomenology, reflective lifeworld

research.

Submitted 30 March 2012, Accepted 31 July 2012

Introduction

Parents have a strong desire to be near their child and

give support and emotional comfort when the condition

of the child requires it (1). Consequences of separation

between preterm newborns and parents have been dis-

cussed in many aspects, thus skin-to-skin care (SSC) has

become common practice in Scandinavian Neonatal

Intensive Care Units (NICUs) since the 1980s. Positive

effects and benefits have been documented through

empirical studies worldwide since the first introductions

of the practice as Kangaroo Mother Care (KMC), inspired

by the Instituto Materno Infantil in Colombia after 1978

Correspondence to:

Ingjerd Gåre Kymre, PHS, Nordland University,

8049 Bodø, Norway.

E-mail: [email protected]

doi: 10.1111/j.1471-6712.2012.01076.x

(2–7). Its main benefits are physiological stabilization,

thermal regulation and stimulation of maternal lactation

(2). Intermittent SSC, which means limited sessions, is

the most implemented method in affluent settings (5).

An expert group of the International Network, from the

7th International Workshop on KMC, 2009, recommends

implementation of continuous KMC as the gold standard

pervading all medical and nursing care, based on empiri-

cal studies and clinical guidelines (5). Decreased pain

response during painful procedures, positive effects on

sleep and improved brain maturation are documented

effects of KMC (5, 7). Other outcomes are psychosocial

aspects like improved parent–infant interaction (5). The

network report suggests that KMC may be used during

terminal care in agreement with parents (5).

A Norwegian study found that care offered to dying

infants and their families changed significantly in many

respects from 1987–1988 to 1997–1998 (8), which

reflected that parents were increasingly more present at

the time of the child’s death and involved in the process

to forgo life support. An increase in the proportion of

dying infants for whom withholding or withdrawal of life

support preceded their death was found. An American

study from the period 1999 to 2008 found that the pri-

mary mode of death in their NICU was the withdrawal of

life-sustaining support (9). Those findings may represent

a trend, and exemplify elements related to the back-

ground of this study context, which concerns situations

in NICUs where medical and nursing staff and the par-

ents realise that the preterm newborn’s condition is not

compatible with life or a decision has been made to stop

life-supporting treatment.

When the neonate is dying, medical staff expected par-

ents to be with the baby, and encourage the parents to

hold him/her (10). According to Armentrout (11), par-

ents have an intense need to carry their deceased new-

born with them as they move forward with their lives,

and she emphasised the importance of providing parents

with an opportunity to spend time with their infant as a

member of the family, without all the tubes and wires.

However, studies concerning the phenomenon of practic-

ing SSC for dying preterm newborns and their parents

are limited.

Aim

The aim of this study, which is part of a larger study on

neonatal nursing care, was to describe the phenomenon

of how nurses enact SSC for dying preterm newborns

and their parents.

Method

The approach that was chosen to this study is reflective

lifeworld research, as developed by Dahlberg, Dahlberg

and Nyström (12), which in its turn is based on the phe-

nomenological philosophy of Husserl and Merleau-Ponty.

The approach assumes an open attitude to the phenome-

non, in this case the nurses’ relationship to SSC in dying.

The aim of lifeworld research is to describe and elucidate

the lived world in a way that expands our understanding

of human being and human experience, and the clarifi-

cation of meaning as it is given (12). Here, it means artic-

ulating what is at stake for nurses when they encourage

SSC between dying preterm newborns and their parents.

The lifeworld refers to the world as experienced. Within

this approach, it is central to illuminate the essence or

structure of meanings that characterises the phenomenon

(13). According to Dahlberg, the essences are their phe-

nomena and the phenomena are their essences. The

research challenge for this study has been to illuminate

the essential structure from this particular context of SSC

to find the style of this particular phenomenon.

Participants

A purposive sample of 18 nurses from three NICUs in

Sweden, Denmark and Norway, (six from each) were

interviewed at their workplace. They were selected by unit

leaders based on the criteria that they were willing to par-

ticipate and were available to be interviewed during two

selected days and afternoons. Nurses who had been work-

ing in a NICU for more than 5 years were preferred. All

available nurses were female, though this was not a crite-

rion. The Swedish nurses had been practicing 3–24 years

(median 13) in a NICU, the Norwegian; 4–22 years (med-

ian 11) and the Danish; 7–22 years (median 12). 12 nurses

had a higher degree or education in paediatric, neonatal,

intensive, surgery or public health nursing, NIDCAP-edu-

cation or other specialized courses. NICUs were selected

because they showed a commitment, through homepages

or in other ways, to SSC as a part of their practice. The

three were all large units. Data collection in three different

countries was meant to possibly represent variations of

experience and meaning.

Interviews

The nurses were asked to describe their lived experiences

concerning the phenomenon that was chosen (12, 14).

The first author carried out the interviews. 17 of the 18

participants answered yes to the opening question: ‘Have

you ever brought a preterm newborn to a parent’s body

for SSC when you knew it was going to die?’ The last

participant had been present when such situations took

place. To find out what they considered important, the

next question was: ‘Can you tell me about one or several

such situations?’ Probing questions were asked to obtain

details, and to clarify unclear statements. The participants

could more or less in detail remember situations of caring

670 I.G. Kymre, T. Bondas

for parents and newborns within this context. The inter-

views took place in November and December 2009, and

the digitally recorded material was transcribed verbatim

during spring 2010. None of the authors had any connec-

tion to the selected NICUs.

Ethical considerations

This study was approved by the Regional Ethical Com-

mittee (15) and the Norwegian Social Science Data Ser-

vices (16), which reviews projects based on guidelines for

research ethics. The research is in line with the ethical

guidelines for nursing research in the Nordic countries

(17). The material was stored according to the guidelines

of the Norwegian National Committee for Research Eth-

ics in the Social Sciences and the humanities, NESH (18).

Permission to carry out the study was obtained from the

head nurses or physician of the hospital units. The nurses

had received a letter that introduced them to the aim of

the interview. Permission to record the interviews was

given from each participant, and participants were

assured that the information would be treated confiden-

tially. The participants were informed about their right to

withdraw from the study at any time.

Analysis

In line with Dahlberg et al. (12), the entire descriptions

were initially read to get a sense of a whole. Preunder-

standing, including personal beliefs and theory drawn

from personal experience with the phenomenon was set

aside in the sense of ‘bridling’, to allow the essential

meaning of the nurse’s utterances to manifest them-

selves. The main point of bridling is to bring us closer to

the meaning of the phenomenon without limiting the

research openness (12).

The descriptions were divided into units of meanings,

which sometimes made it necessary to break up signifi-

cant shifts in meaning. Clusters of descriptions were anal-

ysed and organized, and constitutive elements that

described various meanings to the phenomenon were

identified. A new whole was written to emphasise the

essence of the phenomenon, having in mind that accord-

ing to Dahlberg (13), describing essences is a clarification

of meaning as it is given, and any meaning that we dis-

cover belongs to the phenomenon. The phenomenon

being analysed was SSC for dying preterm newborns and

their parents, and the research process led to a new writ-

ten understanding of the phenomenon’s essential mean-

ing of parts and whole.

Findings

The various and rich descriptions of the phenomenon

indicated that independent of three different participating

Scandinavian countries, the essential meaning of the

phenomenon was expressed as a strong belief in the

urgency of SSC in providing mutual proximity and com-

fort for dying preterm newborns and their parents. The

nurses act upon this belief and upon an engagement in

securing the best possible present and future experiences

of being close, in which the SSC is the preferred caring

practice and is understood as a necessary premise in

achieving the intended optimal conditions for mutuality.

The notion of loss was connected to an importance for

parents of having been close to or with the preterm new-

born for being able to articulate and acknowledge the

meaning of their loss. To provide this aspect, tubes and

wires were removed after the transfer to the parent’s body,

after establishing skin-to-skin contact, sometimes very

quickly because of the newborn’s poor medical condition.

Expressing strong belief

Strong belief was expressed through the ways nurses

described how they reasoned, acted and gave SSC prior-

ity. The notion ‘I believe’ was used, following gestures

underlining strong belief and engagement. Furthermore,

this strong belief was expressed as a commitment in the

context of caring rather than in the context of treatment:

‘I believe it is good for the newborns because I have seen

well-being in preterm newborns receiving SSC so many

times,’ exemplifies how belief is expressed, as well as ‘I

just believe instinctively that dying newborns should not

be alone, but in the arms.’ Alone means in the incubator

or not close to another body. Words indicating a belief in

what are the best possible ways to act were used gener-

ally through the descriptions. ‘She laid skin to skin con-

stantly through two days and nights because we thought

that every moment was her last’ and ‘We have taken out

babies from the incubator because we know there is no

way back’, are examples where an explanation justified

with a ‘because’ indicates an implicit belief in facilitating

SSC as the right thing to do.

Realizing urgency in transferring, and limited, valuable time

for ‘being with’

A quotation that exemplifies how a decision to facilitate

SSC is made without dwelling is, ‘Sometimes I grasp the

urgency of parent’s holding the newborn when it is still

moving.’ When it is realised that the newborn is going to

die, or a decision is made to stop life-supporting treat-

ment, there is no doubt among the nurses asked about

transferring the newborn close to its parent’s body, skin

to skin. ‘The preterm newborn should have the opportu-

nity to be with its parents before passing away,’ a nurse

claimed with an extra emphasis on the notion ‘should’.

Urgency was expressed in terms of giving SSC priority

by describing how the tracheal tube is kept until the

A phenomenological study from the perspective of NICU nurses 671

dying newborn is placed against a parent’s bare chest to

secure that the moment of dying takes place there when

the newborn is still alive. Pulse frequency and other per-

ceptual parameters sometimes indicate limited time and

that the newborn will die very soon, and several nurses

said, ‘We always facilitate SSC if we know the newborn

will not survive.’ In contrast to keeping the tracheal tube,

examples of removing it before transferring from the

incubator were described as stressful and less optimal;

‘The newborn died at once, so it was more dramatic and

shocking than we had expected, – they should have had

more time together.’

A concern about SSC while keeping the newborn alive

beyond a necessary hospital transfer was described, as

well as the concern of not achieving it, and it was

expressed in the following:

Together with the transport, team we made a deci-

sion not to transfer a newborn to another hospital

nearby, because if we did he would have been sepa-

rated from his parents. He would have been placed

into a transport incubator, and if so, the medical staff

would have the responsibility to keep him alive dur-

ing the time of the transport and you cannot do

that, so there was no prospect of moving him. We

let him lie skin to skin, and he took his final breath

on his mother’s chest.

The matter of dignity for the dying newborns was

raised as challenging in regard to simultaneous urgency

of the situation. This manifested itself in terms of a

rapid transfer from the incubator to the parent’s body

when the child is close to death. This included concerns

about the newborns feeling uncomfortable, concerns

that were identified in several descriptions. The transfer

became a problem to which nurses needed to attend by

being sensitive and careful in the practical act of trans-

ferring, in that SSC was still given priority. Occasion-

ally, the newborns do not die very quickly, but nurses

still characterize time with their parents as limited. The

time of being with, skin to skin, was also characterized

as valuable time, whether they managed to have this

time or not.

Expressing engagement

An engagement in skin-to-skin caring was expressed as

double-oriented from the nurse’s perspective. The

descriptions involved how nurses imagined the new-

borns’ experiences, consciousness and feelings, together

with observing and understanding physiological parame-

ters. ‘Actually, I do not know how conscious the new-

born is, or about its sensory experience,’ was expressed

by one nurse, and another said,

‘Because he was very ill, I am uncertain of what he

was sensing. I think it depends on the various physi-

cal condition and medications, if they are conscious

or in a doze, but I believe that the skin-to-skin con-

tact is good for the newborns’.

A projection of dying newborns having a feeling of being

scared was expressed: ‘I think that skin-to-skin contact

will help the newborn in not feeling scared of experienc-

ing the lack of air.’

An engagement with how parents experience the situ-

ation was as an example expressed by a nurse’s reflec-

tions about how difficult it must be not to have had the

chance to ‘hold your newborn close to your body, – I

think it is a deep-seated need in women to feel their

baby against their skin,’ she said.

Facilitating mutual proximity and comfort

A lived particular example of the SSC in a situation of

dying was this; ‘He was lying naked in her arms in that

the mother could see his face, he was just wearing a dia-

per, she lay in a bed and she held him into her skin

against her breast. Then we removed the tracheal tube.’

Experiencing closeness, touch and comfort is empha-

sized as an aim in terms of both giving and receiving

between the dying newborn and its parents. A receiving

dimension was exemplified by quotations such as ‘A

newborn should not have to die alone, but feel the prox-

imity’, and ‘The newborn receives proximity the short

time it is here’ Another said, ‘Both the parents and the

newborn should get the opportunity to feel the proximity

even if there is an awful incident going on’

In addition, a giving dimension was described as,

‘There is no other way that you can transmit that you

are close, more than through skin-to-skin contact’. and

‘They were with him, and could follow him on his way,

in that he was not alone.’

Skin-to-skin care was also expressed as a way to pre-

vent suffering. A nurse said that she hoped that the baby

would experience comfort just for a short while ‘to let

the baby perceive safety in hearing the mother’s heart

and voice’, and further, ‘as long as the baby is able to

feel the mother’s heart beat, he or she shall do so, I

think.’ Another description expressed the quality of SSC

as ‘Contact with skin is different from contact with fab-

rics,’ and feeling comfort skin to skin, noted some,

included absence of pain and hunger.

A few experiences exemplified exceptions from the

norm of the mutual dimension of closeness in that the

parents were not present, and nurses were with the new-

born in the dying process by holding and touching the

baby. They described themselves sitting with the new-

born in their arms, to let the parents have some sleep,

pointing to the importance of not leaving the newborn

alone in this condition, under any circumstances. A

nurse said, ‘It was important for the parents that the

newborn had skin-to-skin contact continuously, so I sat

with their dying newborn skin to skin against my arm.’

672 I.G. Kymre, T. Bondas

She had not told anybody, but it made her determined

afterwards never to let a newborn die without SSC, and

this was something she encouraged other nurses to prac-

tise as well. Another example concerned a newborn boy

who died suddenly, whose parents could not immedi-

ately be contacted by the medical staff, so that they could

get there when he was still alive. The nurse was glad to

tell them that she held his hand as long as he was alive,

because that was something, even if it was not optimal.

The thought of letting a newborn die alone in the incu-

bator gave her a feeling of emptiness.

Securing the best possible present and future experiences by

skin-to-skin care

The importance of securing that the parents had felt that

the baby was ‘real’ was underlined and the statement of

the newborn as ‘having been’ was connected to the

touch of a living body. One nurse said vividly:

When the parents have got the baby on their bare

skin on the chest, and when they have perceived his

presence, it is not something unreal, because he

actually was here (puts her hand on to her own

chest). I think it is an important matter, that they

have held him here.

This quotation, underlined by using a gesture, exempli-

fies that the experience of something real and actually

felt was connected to future experiences through

remembering.

The nurses used notions connected to the context of

SSC in how they understood a parent’s perspective of

bonding, accepting loss, adopting emotionally, the end as

something beautiful, feeling closeness, following him on

his way, peacefulness and crossing a border. Crossing a

border meant doing something not easily done or with

which one is not familiar.

‘I believe that it is meaningful that they get something

good to carry with them, something to remember. They

can say that they have lost a child’, one nurse said. Both

she and others referred to human touch skin to skin and

to the act of holding closely. This was often connected to

the idea of providing the best possible memories to look

back on. When the nurses reflected on how they imag-

ined the parents remembering, they mentioned both the

experience of holding close and the experience of the

‘picture’ of the newborn.

Collecting physical objects was described, while nurses

often help parents take photographs, footprints and

sometimes tiny locks of the baby’s hair to provide physi-

cal memories for remembering their newborn. Some

described placing the newborn’s body in a position that

makes it possible for the parent to see the face without

tube and tape, maybe for the first time ever. Remember-

ing a nice and peaceful ‘picture’ of the newborn was

emphasised, and described in terms of the look on the

babies face, skin colour, clean blankets and absence of

medical equipment covering the body. To provide time to

hold the baby when it is still warm was emphasised as

something that could give parents a better experience to

remember than the touch of a cold body.

In describing urgent situations, the environmental con-

ditions were generally not focused on as an important

matter. In contrast, one of the nurses had noticed the

impersonal room, but she got the impression that the

parents did not notice the environment, because they

focused on the holding experience. According to partici-

pants, there is an aspiration towards as much privacy as

the situation allows, even to the extent of transferring

other patients.

Persuading the parents to hold their dying newborn skin to

skin

The nurses described deviations in the experience of

what parents are able to cope with in their grief in losing

their newborn baby. They pointed to the importance of

careful approach to how they facilitate closeness. ‘We

cannot push them too hard’, was said. The very first SSC

is sometimes a threshold to cope with, especially if the

newborn is critically ill or dying. If parents have not held

the living baby, there is often more resistance to hold the

dead baby. One nurse said, ‘I will not push them if they

won’t, but I will always try to persuade them to hold the

child close’.

Events concerning parents who do not want to touch

or hold the dying newborn were among the descriptions.

‘Even when we meet parents who decline to hold the

deceased newborn, we try to convince them,’ a nurse

said. She continued, ‘We seldom meet parents who don’t

want to, but it makes us concerned’. Descriptions

referred to declining and showing fear in parents, and

how nurses meet this reaction with being concerned, and

if parents decline being close to the dying newborns,

nurses sometimes try to persuade them to hold them skin

to skin. But still, a few parents choose to keep aloof from

their dying newborn, and nurses save footprints, hair-

locks and pictures for them. However, the common expe-

rience among the participating nurses was that parents

are thankful for being helped to cross the threshold of

getting close to the child they were about to lose.

Discussion

The nurses’ strong belief in the urgency of SSC in provid-

ing mutual proximity and comfort for dying preterm

newborns and their parents, expresses the essential

meaning of the phenomenon.

Essential meaning is built upon constituents concern-

ing both the aspect of how the phenomenon was

focused, as well as the aspect of what the nurses focused

A phenomenological study from the perspective of NICU nurses 673

on that belongs to the phenomenon. How the phenome-

non is focused was expressed through strong belief and

engagement. What they focused on was expressed as

facilitating mutual proximity, securing the best possible

present and future experiences by SSC, and persuading

the parents to hold their dying newborn child skin to

skin.

This study is limited to research on how nurses act in

this context and therefore their perspective was illumi-

nated. According to Bondas (14), phenomenological

research has the potential to challenge previous knowl-

edge and practice in postpartum care and to develop new

caring science knowledge, evident for clinical caring prac-

tice. How can the essential meaning from NICU nurses’

caring practices in this study be elaborated within neona-

tal science, caring science and a phenomenological

approach? This work’s contribution will be illuminated in

the following.

In his Introduction to Phenomenology, Sokolowski

(19) wrote that the core doctrine is the teaching that

every act of consciousness we perform and every experi-

ence that we have is intentional, which in this discussion

is understood in terms of how meanings are something

essential intended. From this understanding, the constit-

uents that make the structural essence of this phenome-

non indicate that nurses are intending mutual closeness

and comfort both as a present and a future experience.

In recognizing the double caring focus by SSC in this

study, the relational aspect was emphasised. Expressions

of an urgent importance of facilitating both a giving and

a receiving dimension of the SSC emphasize nurses’

intentions to facilitate a mutual experience in parents

and dying preterm newborns in NICUs.

In 1959, Maurice Merleau-Ponty (20) wrote about

‘Chiasm’, as opposed to ‘For the other,’ meaning that

there is not only a me-other rivalry, but a co-functioning

relationship. Merleau-Ponty’s concept of flesh and chi-

asm captures the reciprocity of the mother–infant rela-

tionship, according to Wynn (21). She highlights those

thoughts by maintaining that the holding relationship

becomes reversible, in which mother and infant are hold-

ing and held and the touch is about touching and being

touched, and that they both actively constitute the rela-

tionship. The infant plays a dynamic part in holding.

Therefore, holding and being held and touching and

being touched, constitute a chiasmic relationship. Wynn

contends that mothering is a bodily practice, an idea that

is also supported by Broeder (22), who asks for a better

understanding for intuitive bodily care-giving and con-

nectedness felt by mothers at first holding their preterm

newborns. Broeder was concerned with the psychical

health of mothers, based on the profound aching and loss

that the mothers feel while separated from their new-

born, unable to physically hold it. The focus that nurses

in this study had on the importance of SSC and their

engaged relation to the newborns’ feelings, shows an

understanding of the newborn as conscious in some way,

and ‘not being left alone’ seems to be equivalent to phys-

ical contact and comfort.

Development of mutual interaction and affinity

between mothers and healthy full-term newborns was

also emphasised as essential in a study of mother’s expe-

riences of SSC the first days after birth (23). That study

illustrates a view on SSC that illuminates both similar

and contrasting knowledge to this study. The understand-

ing of mutuality is common as essential, but the nursing

perspective, the context and the constituents differs,

which indicate different phenomena where the intending

acts and objects differ, as does the contextual variation.

Both studies emphasise the double caring focus on parent

and child as a unity in SSC.

Facilitating SSC is given priority in this study, but

sometimes nurses were challenged by parents who

decline closeness to their dying neonates. Fegran found

that nurses gradually master technical and instrumental

tasks, but many of the nurses in that study found inter-

action with parents to be much more challenging and

demanding (24). Parents of extremely preterm newborns

experienced the immediacy with which decisions had to

be made, particularly whether to see and hold the new-

born before death, according to Kavenaugh (25), when

she suggested in 1997 that parents may not be prepared

emotionally to hold the newborn at the actual time of

death. Thus, in 1998, Lundqvist and Nilstun (26)

reported that most of the nurses in a study were inclined

to give priority to the principle of the beneficence of see-

ing, touching and holding the dead or dying newborn.

Some nurses experienced a personal failure if they were

unable to persuade the mothers to hold their dead baby.

In a 2002 study, Lundqvist, Nilsstun and Dykes (27)

found that most of the mothers felt from the bottom of

their hearts that they wanted to hold their still-living

baby, but did not have the courage to, because of fear.

Persuasion by the staff was found to be supportive, and

healthcare professionals expressed the opinion that it was

important for the mothers to hold their baby during the

dying process. In Bondas’ 2005 study (28), new mothers

experience that they are with child, even when the child

is not momentarily there or they have lost the baby early

in the pregnancy. Women who did not have the baby on

their chest after birth expressed disappointment and sad-

ness years afterwards, according to Lundgren et al. (29).

Moro et al. (30) suggest that a majority of parents may

want to be a part of the dying process and found solace

in being able to hold their baby before and after death,

but a minority preferred to have limited or no involve-

ment. This study, however, illuminates that strong belief

in nurses at the participating NICUs is present in how the

intended essence of being with is expressed through the

practical act of persuading or influencing the parents.

674 I.G. Kymre, T. Bondas

Skin-to-skin care in dying was not discussed in the

studies mentioned above, which may indicate a changing

practice of holding dying preterm newborns parallel to

the developing use of SSC in general. Therefore ‘strong

belief’ in practical embedded knowing in this context in

all likelihood is influenced by paradigmatic and historical

science and habits. According to Charpak and Ruiz (2),

KMC has brought to reality a new paradigm in the care

of preterm infants, to avoid mother–infant separation

from the very beginning of extra-uterine life. The discus-

sion places this study historically in line with studies con-

cerning implementation of SSC or KMC 24 hours a day

in NICUs. Thus, SSC in a situation of dying is, according

to this study, a kind of intervention built on strong belief

in what is the right thing to do, where the only obstacle

is occasional reluctance of some parents to participate.

From the nurse’s perspective, however, this participation

is necessary in making the phenomenon a meaning-giv-

ing activity, and need to be encouraged.

This knowledge about the phenomenon indicates that

SSC is not only a way to proceed when a preterm new-

born is dying, but a necessary premise in achieving the

intended optimal conditions for mutuality.

Conclusions and implications for practice

Skin-to-skin care for dying preterm newborns and their

parents is the preferred caring practice, understood as a

necessary premise in achieving optimal conditions for

mutuality. Therefore, it is of major importance to facili-

tate proximity and comfort through SSC when the new-

born is still alive.

A strong belief in its urgency indicates that SSC in the

situation of dying has become embedded in caring prac-

tice among Scandinavian NICU nurses and belongs to a

new paradigm in the care of preterm infants, which is

committed to avoiding mother–infant separation from

the very beginning. A double caring focus on the mutual

experience of skin-to-skin contact in the parent–newborn

relationship is acknowledged and respected for its human

values, where the dying preterm newborn is seen as an

active as well as a passive agent.

The authors suggest this practical knowledge from

NICU nurses perspective to be acknowledged in discus-

sions concerning end-of-life care for preterm newborns

and their parents and we recommend more formal estab-

lishment of this practice.

Further research is needed on the experience of par-

ents in relation to SSC in this vulnerable situation of

‘being with’ their dying newborn.

Acknowledgements

The authors would like to thank the participants for

helping us undertake this study. We want to thank Pro-

fessor and philosopher James McGuirk for his contribut-

ing reflections and supervision, and Associate Professor

Jessica Allen Hansen for revising the English text.

Conflict of interest statement

The authors declare that there is no conflict of interest.

Author contributions

Both authors contributed to this article. The idea of the

study, data collection, preliminary analysis work and

drafting of the manuscript was performed by PhD student

Ingjerd Gåre Kymre. Professor Terese Bondas regularly

met with Ingjerd Gåre Kymre for reflection and supervi-

sion and contributed to critical revision.

Ethical approval

The Regional Ethical Committee, REK Nord, who found

further proposal of the study not obliged. Document ref-

erence; 2009/106-18. The Norwegian Social Science Data

Services, NSD, http://www.nsd.uib.no/ which reviews

projects based on guidelines for research ethics registered

it with the project number: 22199.

Funding

Funding was not obtained.

References

1 Wigert H, Berg M, Hellström A-L.

Parental presence when their child is

in neonatal intensive care. Scand J

Caring Sci 2010; 24: 139–46.

2 Charpak N, Gabriel Ruiz J. Kangaroo

mother care: past, present and

future, editorial. Curr Womens Health

Rev 2011; 7: 227–31.

3 World Health Organization. Kanga-

roo Mother Care, a Practical Guide.

2003, www.who.int/reproductive-health/

publications/kmc/ (last accessed 17

September 2012).

4 Lawn JE, Mwansa-Kambafwile J,

Horta BL, Barros FC, Cousens S.

Kangaroo mother care to prevent

neonatal deaths due to preterm birth

complications. Int J Epidemiol 2010;

39: il44–54.

5 Nyqvist KH, Anderson GC, Bergman

N, Cattaneo A, Davanzo R, Ewald U,

Ludington‐Hoe S, Mendoza S, Pallas-

Allonso C, Pelaez JG, Sizun J, Wid-

strom A-M. State of the art and rec-

ommendations. Kangaroo mother

care; application in a high-tech envi-

ronment. Acta Paediatr 2010; 99:

812–9.

6 Chia P, Sellick K, Gan S. The atti-

tudes and practices of neonatal

nurses in the use of Kangaroo Care.

Aust J Adv Nurs 2006; 23: 20–27.

7 Ludington-Hoe SM. Evidence-based

review of physiologic effects of

A phenomenological study from the perspective of NICU nurses 675

Kangaroo Care. Current Women’s

Health Reviews 2011; 7: 243–53.

8 Hagen CM, Hansen TW. Deaths in a

neonatal intensive care unit: a 10-

year perspective. Pediatr Crit Care Med

2004; 5: 463–68.

9 Weiner J, Sharma J, Lantos J, Kil-

bride H. How infants die in the neo-

natal intensive care unit, trends form

1999 through 2008. Arch Pediatr Ado-

lesc Med 2011; 165: 630–4.

10 Lundquist A, Nilstun T, Dykes A-K.

Neonatal end-of-life care in Sweden.

Nurs Crit Care 2003; 8: 197–202.

11 Armentrout D. Holding a place: par-

ents lives following removal of infant

life support. Newborn Infant Nurs Rev

2007; 7: e4–11.

12 Dahlberg K, Dahlberg H, Nyström M.

Reflective Lifeworld Research. 2008.

Studentlitteratur, Lund, Sweden.

13 Dahlberg K. The essence of essences

– the search for meaning structures

in phenomenological analysis of

lifeworld phenomena. Int J Qual Stud

Health Well-being 2006; 1: 11–19.

14 Bondas T. Husserlian phenomenol-

ogy reflected in caring science child-

bearing research. In Qualitative

Research in Midwifery and

Childbirth – Phenomenological

Approaches (Thomson G, Dykes F,

Downe S eds), 2011, Routledge, Lon-

don and New York, 1–18.

15 Regional Ethical Committee North.

www.etikkom.no (last accessed 17

September 2012).

16 Norwegian Social Science Data Ser-

vices (NSD). http://www.nsd.uib.no/

(last accessed 29 June 2009).

17 Northern Nurses Federation. Ethical

Guidelines for Nursing Research in the

Nordic Countries. 2003. www.ssn-nnf.

org (last accessed 17 September 2012).

18 Norwegian National Committee for

Research Ethics in the Social Sci-

ences and the Humanities (NESH).

2006. www.nsd.no (last accessed 20

February 2009).

19 Sokolowski R. Introduction to Phe-

nomenology. 2007, Cambridge Uni-

versity Press, New York, USA.

www.cambridge.org (last accessed 17

September 2012), ISBN 978-0-521-

66792-0.

20 Merleau-Ponty M. The Visible and

the Invisible: followed by working

notes (Lefort C ed.), translated by

Alphonso Lingis. 1968, Northwestern

University, Studies in Phenomenol-

ogy& Existential Philosophy, Evan-

ston, USA: Northwestern University

Press, ISBN 978-0-8101-0457-0,h,

0-8101-0457-1,h.

21 Wynn F. The embodied chiasmic

relationship of mother and infant.

Hum Stud 1997; 19: 253–70.

22 Broeder JL. Mothers’ early embodied

and relational responses to their pre-

term infants. J Assoc Res Mother 2009;

11: 71–79.

23 Dalbye R, Calais E, Berg M. Mothers’

experiences of skin-to-skin care of

healthy full-term newborns – a

phenomenology study. Sex Reprod

Healthc 2011; 2: 107–11.

24 Fegran L. The parent-nurse relation-

ship in the neonatal intensive care

unit context – closeness and emo-

tional involvement. Scand J Caring Sci

2008; 23: 667–73.

25 Kavenaugh K. Parents’ experience

surrounding the death of a newborn

whose birth is at the margin of

viability. JOGNN 1997; 26: 43–51.

26 Lundquist A, Nilstun T. Neonatal

death and parents grief. Scand J Car-

ing Sci 1998; 12: 246–50.

27 Lundquist A, Nilstun T, Dykes A-K.

Both empowered and powerless:

mothers experiences of professional

care when their newborn dies. Birth

2002; 29: 3.

28 Bondas T To be with child: a heuris-

tic synthesis in maternal care. In

Trends in Midwifery Research (Balin

R ed.), 2005, Nova Science, New

York, 119–36.

29 Lundgren I, Karlsdottir SI, Bondas T.

Long-term memories and experi-

ences of childbirth in a Nordic con-

text – a secondary analysis. Int J

Qual Stud Health Well-being 2009; 4:

115–28.

30 Moro T, Kavenaugh K, Okuno-Jones

S, Van Kleef JA. Neonatal end-of life

care, a review of the research litera-

ture. J Neonat Nurs 2006; 20: 262–73.

676 I.G. Kymre, T. Bondas

Copyright of Scandinavian Journal of Caring Sciences is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.