The Lived Experience of Nurses and Midwives Implementing a Clinical Practice Guideline for Care ...

182 Pages·2012·0.92 MB·English

The Lived Experience of Nurses and Midwives
Implementing a Clinical Practice Guideline for
Care of the Nutritionally Compromised Infant

by
Shane Parisotto

A thesis submitted for the degree of
Master of Nursing (Research)

Discipline of Nursing
School of Health Sciences
Faculty of Health
University of Canberra

March 2012

Supervisors
Dr Jan Taylor Dr Jenny Browne
Associate Professor Associate Professor
Disciplines of Nursing & Midwifery Disciplines of Nursing & Midwifery
Faculty of Health Faculty of Health
University of Canberra University of Canberra
ABSTRACT
In early infancy the body is developing at a rapid rate and the consequences of poor
nutrition can be devastating. Evidence suggests these infants will have poorer outcomes
with lasting effects including chronic poor eating behavior resulting in underweight,
obesity and in severe cases, death. Identifying infants experiencing compromised
nutrition and implementing appropriate management strategies is essential in ensuring
better health outcomes for these infants and their families. The use of evidence-based
guidelines is one of the most effective tools for improving the quality of care. Changing
practice is challenging and a better understanding of the experiences of health
professionals who engage in using evidence-based guidelines in complex situations is
required. The purpose of this study was to describe and interpret nurses’ and midwives’
experience of implementing a clinical practice guideline for care of nutritionally
compromised infants in a primary health care setting. The research employed a
hermeneutic interpretative phenomenological design. A purposive sample of nurses and
midwives, recruited from a Family Centre, generated data through eleven interviews and
one focus group. Phenomenological analysis was informed by Van Manen’s (1990)
concurrent procedural steps. Four major themes emerged. They included Pathway to
Awareness, Depth of Practice, Identifying and Acknowledging the Issue and Mothers’
Milk. The essence of the participants’ experience revealed their strongly held belief that
‘breast was best’ to promote optimal infant growth and development and this may have
been compromised by implementing some of the management strategies outlined in the
guideline. This research highlights two issues. First, nurses’ and midwives’ capacity for
change is enhanced when their beliefs and feelings are acknowledged and when shared
dialogue and support mechanisms are incorporated into the phases of implementing a
guideline. Second, further research exploring the effects of complementary formula
feeding on infant breast feeding behaviour and maternal capacity to generate optimal
breast milk supply may further assist nurses, midwives and clients in making decisions
regarding care of nutritionally compromised infants.

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ACKNOWLEDGEMENTS

Travelling a journey through unchartered territory is often challenging. The not knowing
of what lies ahead is exciting yet daunting. Learning, experiencing and being in the
moment bring to light a depth of understanding. The doing of this thesis has not been
accomplished without support, guidance and love. My passage has been enriched by
family, friends, colleagues, children and their carers. To my partner, Rob, I thank you for
all the dinners you have provided, your thoughtful comments and unconditional love.
Tess and Josh, your love, friendship and being there for me, I value with all of my heart.
Mum, Jennifer, Ralph and Kath, you are my rocks, believing in me, grounding me,
providing love and support. Lorraine, Joanne, Anna and Guido, I thank you for being
there when I needed you the most. And my Dad, who inspires me to grow and know the
world in a very special way, words are not enough, you will always live and hold a very
special place in my heart. I love you Pop and thank you for nurturing me through tough
times. A very special thank you to Mary for believing in me, giving me courage, a gentle
nudge, valuing my contribution and providing amazing support. I am overwhelmed by
your capacity to be generous in so many ways. My gratitude extends to Emma providing
valuable resources and encouragement. Judy and Liz, thank you for caring and
reminding me to be kind to myself. To all my work colleagues, you know who you are. I
thank you for providing me with critical challenge, support and encouragement to
continue. Together we provide a powerful and meaningful voice. Positive feedback,
focus and wisdom from the wise women, Jan and Jenny, what a team you are, without
your direction this thesis would not have evolved. I am grateful for your words and the
invaluable support and resources from the University of Canberra. I would like to direct
sincere appreciation to all participants of this study and to the carers of all the infants who
imparted their stories through the participants. And finally, I am blessed to have shared
time with all the very precious infants who quietly and sometimes very loudly opened a
window into our collective consciousness imploring to be heard, seen, acknowledged and
nurtured. I hope we have listened and are on course providing the care you deserve.

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CONTENTS

ABSTRACT………………………………………………………………………………v
ACKNOWLEDGEMENTS……………………………………………………………..vii
CONTENTS………………………………………………………………………………ix
LIST OF FIGURES……………………………………………………………………..xiii
DEFINITION OF TERMS……………………………………………………………....xv
CHAPTER 1 INTRODUCTION………………………………………………….……..1
Context for Research……………………………………………………………………....2
Significance of the Study…………………………………………………………….........6
Purpose of the Study: Illuminating Parts and the Whole………………………………….8
Summary ………………………………………………………………………………….8
CHAPTER 2 LITERATURE REVIEW…………………………………………………9
Introduction ……………………………………………………………………………….9
Clinical Practice Guidelines and Evidence-Based Practice….……………………………9
Classification of the Nutritionally Compromised Infant ...……………………………...15
Factors contributing to the Infant’s Compromised Nutritive State ……………………..22
Definition ……………………………………………………………………………….34
Management Strategies ....................................................................................................36
Possible Outcomes for the Nutritionally Compromised Infant ........................................40
Summary............................................................................................................................41
CHAPTER 3 METHODOLOGY & METHOD………………………………………..43
Introduction………………………………………………………………………………43
Hermeneutic Interpretative Phenomenology………………………………………….....43
ix
Method…………………………………………………………………………………...49
Participants…………………………………………………………………………….....49
Ethics …………………………………………………………………………………….50
Rigor and Trustworthiness……………………………………………………………….51
Phenomenological Direction …………………………………………………………….52
Turning to the Nature of the Lived Experience …………………………………54
Engaging in Existential Investigation……………………………………………54
Data Collection …………………………………………………………54
Engaging in Phenomenological Reflection & Writing …………………………57
Phenomenological Analysis ....................................................................57
Reflection and Discussion .......................................................................59
Summary…………………………………………………………………………………60
CHAPTER 4 PHENOMENOLOGICAL ANALYSIS……………………………….…63
Introduction………………………………………………………………………………63

Pathway to Awareness…………………………………………………………………...64
Depth of Practice…………………………………………………………….…………..78
Identifying and Acknowledging the Issue……………………………………………….87
Mothers’ Milk ……………………………………………………………………….…97
Summary .………………………………………………………………………………117
CHAPTER 5 PHENOMENOLOGICAL REFLECTION ..…………………………119
Introduction …………………………………………………………………………….119
Change is Challenging …………………………………………………………………120
Focus on Education and Support of the Primary Carer in Caring for their Infant .........123
x
Feeling unsettled at Times when Approaching Infant Health Assessment ………… 124
Torn between the Need to Rescue the Primary Carer or the Infant or Both …………126
Emotional Conflict when considering the Best Interests of the Infant and Mother ……131
The Fundamental Nature of the Participants’ Experience ……………………………..136
Summary ……………………………………………………………………………….137
CHAPTER 6 CONCLUSION…………………………………………………...…….139
Introduction……………………………………………………………………………..139
Purpose………………………………………………………………………….………139
Significance, Strengths and Weaknesses………………………………………….……139
Final Summation……………………………………………………………….……….140
Recommendations............................................................................................................141
Conclusion ......................................................................................................................144
RESEARCHER’S FINAL PHENOMENOLOGICAL THOUGHTS………………….145
REFERENCES…………………………………………………………………………147
APPENDIXES……………………………………………………………….…………159
Appendix A Clinical Practice Guideline ……………………………………………....159
Appendix B Information Letter ………………………………………………………..167
Appendix C Information Form .......................................................................................173

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LIST OF FIGURES

1. Process of Evidence-based Practice …………………………………………….10
2. Variables impacting on infant/primary carer feeding relationship ….………….24
3. Adapted descriptive model depicting interaction between perceived barriers to
breast-feeding (Stewart-Knox 2003). ………………………………………….. 29
4. The basic form of the hermeneutic circle (Bontekoe, 1996 p.4) ……………… 56
5. The process of analysis and reflection …………………………………………..59

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DEFINITION OF TERMS

ACT Australian Capital Territory
Breastfeeding
This terminology has been adopted by the World Health Organisation
and supported by the Australian National Breast Feeding Strategy (ACT
Health 2010 p.5).

Exclusive breastfeeding
Infants receive only breast milk, including expressed breast milk and,
where required, medicines, but no infant formula or non human milk.

Complementary or partial breastfeeding
The infant may receive semi solid or solid food in addition to breast milk.
This may include any foods or liquids, infant formula and non human
milk.

Supplementary breastfeeding
The infant may receive one or more fluid feeds including breast milk
substitutes eg: infant formula in place of a breastfeed.

CDC Centers for Disease Control and Prevention
FTT Failure To Thrive
Galactogue Described by the participants in this study as a medication or herbal
preparation that promotes the secretion and flow of milk.

NCHS National Center for Health Statistics
NHMRC National Health Medical Research Council
Nutritionally Compromised Infant
The Family Centre referred to in this study defines the term as: infants
aged 0-3 years who fail to make expected age-appropriate gains in weight.

PAHO Pan American Health Organisation
PANDA Post Ante Natal Depression Association
UNICEF United Nations Children's Fund
WHO World Health Organisation
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CHAPTER 1
INTRODUCTION

Oh it’s really hard. It’s actually amazingly… oh!! I’ve got a nutritionally compromised
infant and although I think it shouldn’t be that hard …you look and your heart, there’s
this emotional thing where you think, right we’re going to have to make a move here ...
what are we doing to make a difference? (Participant 2).

I guess I'm frustrated by the fact that they are there for five days and how long does it
take to establish or increase the milk …So in an ideal world it would be great to just be
going let's really work on the supply. But in the meantime you've got a baby that… hasn't
got the nutrition there and you want that nutrition … (Participant 6).

1
I think it was the formula comp that raised the bigges t issues amongst the staff. … I
would say that the experience was fairly tumultuous. … some people embraced it, some
people said this is just ... not right. So we had a lot of discussions between the staff
members about the guideline and so actively implementing it was I think fairly tricky for
a lot of us because of those varied opinions and ideas, despite having been given that
guideline. Yeah it wasn't smooth at all. It was quite tricky for different staff (Participant
10).

1
Sometimes the participants in this study used the word ‘comp’ when referring to complementary formula feeds.
1
Context for Research
Implementing a clinical practice guideline for care of the nutritionally compromised infant was a
complex phenomenon undertaken by the nurses and midwives at a Family Centre located in
Australia. The term “nutritionally compromised infant”, adopted by the Family Centre, defines
an infant aged 0-3 years “who fails to make expected age-appropriate gains in weight”
(Appendix A, p.1). This term was developed by the Family Centre following a review of the
literature regarding language that promoted “engagement with the client”, allowed for a
“spectrum” of “levels” identifying poor infant nutritional status and “supported nurses and
midwives to define a complex clinical presentation within a primary health care context” (Family
Centre Director of Nursing and Midwifery/Executive Officer, Personal communication,
st
December 1 , 2011). Terms used by other experts to describe these infants included faltering
growth, undernutrition, underweight, nutritional deficiency, malnutrition, and failure to thrive
(FTT) (de Onis, Blössner, Borghi, Frongillo & Morris, 2004; Block et al, 2005; Emond, Blair,
Emmett & Drewett, 2007; Fishman et al., 2004; O’Brien, Heycock, Hanna, Watts Jones & Cox,
2004; Rosenberg, Brown & Gawinski, 2008).

Researchers agree adequate nutrition is vital to support growth, particularly in the first 2 years of
life (PAHO/WHO, 2004; Wells, 2002). Gabriela Mistral (1948) a Nobel Prize laureate,
emphasized the significance of this belief writing “…now is the time his bones are being formed,
his blood is being made, and his senses are being developed” (WHO, 2011, p.1). During this
time the body is developing at a rapid rate and the consequences of poor nutrition can be
devastating especially if slowed growth occurs before 6 months of age. Evidence suggests these
infants will have poorer outcomes with lasting effects (Skuse, 1985; Wells, 2002). Children with
2