Jilu Thesis.

“A STUDY TO ASSESS THE VIEW OF NURSES REGARDING MANAGEMENT
OF ENVIRONMENTAL STRESS AMONG HIGH-RISK NEWBORN ADMITTED

IN NEONATAL INTENSIVE CARE UNIT (NICU) IN SELECTED HOSPITALS,
BANGALORE WITH A VIEW TO DEVELOP AN INFORMATION BOOKLET.”
By
MS. JILU JAMES
Dissertation submitted to the
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In Partial fulfilment
of the requirements for the degree of
Master of Science in Nursing
In
Paediatric Nursing
Under the guidance of
MRS.R.RAMALAKSHMI MSc (N)
Asst. Professor
Dept of Paediatric Nursing
T. John College of Nursing
Gottigere, Bangalore-83.
2013
I
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation/thesis entitled “A STUDY TO ASSESS THE
VIEW OF NURSES REGARDING MANAGEMENT OF ENVIRONMENTAL
STRESS AMONG HIGHRISK NEWBORN ADMITTED IN NEONATAL
INTENSIVE CARE UNIT (NICU) IN SELECTED HOSPITALS,
BANGALORE WITH A VIEW TO DEVELOP AN INFORMATION BOOKLET.”
is a bonafide and genuine research work carried out by me under the guidance of
Asst. Prof. Mrs. R. Ramalakshmi, (HOD), Dept of Paediatric Nursing, T. John
College of Nursing, Gottigere, Bangalore.
Date: Signature of the Candidate
Place: Bangalore Ms. Jilu James
II
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation entitled “A STUDY TO ASSESS THE
INTENSIVE CARE UNIT (NICU) IN SELECTED HOSPITALS, BANGALORE
WITH A VIEW TO DEVELOP AN INFORMATION BOOKLET” is a bonafide
research work done by Ms. Jilu James in partial fulfilment of the requirements for the
degree of Master of Science in Nursing in Paediatric Nursing.
Date: Signature of the Guide
Place: Bangalore Mrs. R. Ramalakshmi
Asst. Professor, (HOD)
Department of Paediatric Nursing
T. John College of nursing
Bangalore.
III
ENDORSEMENT BY THE HOD, PRINCIPAL / HEAD OF THE INSTITUTION.
This is to certify that the dissertation entitled “A STUDY TO ASSESS THE
INTENSIVE CARE UNIT (NICU) IN SELECTED HOSPITALS, BANGALORE
WITH A VIEW TO DEVELOP AN INFORMATION BOOKLET” is a bonafide
research work done by Ms. Jilu James under the guidance of Asst. Prof. Mrs. R.
Ramalaksmi, (HOD), Dept. of Paediatric Nursing, T. John College of Nursing,
Bangalore.
Mrs. R. Ramalakshmi Prof. Mrs. P. Neelavathi

Asst. Professor Principal
HOD, Dept. of Paediatric Nursing. T. John college of Nursing
T. John College of nursing. Bangalore.
Bangalore.
Date: Place: Bangalore.
IV
COPY RIGHT
Declaration by the candidate
I hereby declare that the Rajiv Gandhi University of Health sciences,
Karnataka shall have the rights to preserve, use and disseminate this dissertation/ thesis
in print or electronic format for academic/research purpose.
Date: Signature of the candidate,
Place: Bangalore. Ms. Jilu James.
© Rajiv Gandhi University of Health Sciences, Karnataka
V
ACKNOWLEDGEMENT
“This is the lord’s doing; it is marvellous in our eyes.”
(Psalms -118.23)
First and foremost I thank and praise the God Almighty for giving all wisdom,
strength and guidance to complete this study successfully.
I am extremely thankful to Dr. Thomas. P. John, Chairman, T. John Group of

Institutions for giving me an opportunity to pursue my post graduation course in this
esteemed institution.
I would like to express my heartfelt gratitude and regard to my guide

Asst. Prof. Mrs. R. Ramalakshmi, (HOD) Dept. of Paediatric Nursing, T. John college of
Nursing for her valuable guidance and support to carry out the dissertation work
successfully.
I would like to express my heartfelt gratitude and regard to

Prof. Mrs. P. Neelavathi, Principal, T. John college of Nursing for her valuable guidance
and support to carry out the dissertation work successfully.
I am profoundly indebted to Mrs. Gladish George, HOD, Dept. of Medical

Surgical Nursing for her guidance and encouragement in every steps of the study.
Heartfelt thanks to Mrs. Uma Maheswari, Lecturer, Dept. of Paediatric nursing,

T. John College of Nursing for her valuable guidance and practical advices.
I would like to thank Mrs. Dr. Prof. Ruby john, Statistician for her guidance and
support in the statistical analysis.
Heartfelt thanks to all the MSc faculties of T John College of Nursing for their
valuable guidance and practical advices.
VI
Thanks to all librarians and all non teaching staffs, T. John College of nursing,
for providing all the facilities for the completion of the study.
I extend my sincere thanks to Mrs. Vijayalakshmi, English Lecturer for editing
my thesis.
It is my pleasure and privilege to express my deep sense of gratitude to
Mrs. Silvi John, Dept of Paediatric Nursing, Nursing, Oxford college of Nursing,
Bangalore, for her encouragement.
I express my sincere thanks to Mrs. Tintu C. Francis, Lecturer, T. John college

of nursing, for her encouragement.
I express my sincere thanks to Mr. Venkatesh.M.P, HOD, Vinayaka mission

College of Nursing, for his encouragement.
My special thanks to all the subject experts who spent their valuable time for
validating my tool.
I extend my hearty thanks to Management & Head of Institution of Indira

Gandhi Institute of Child Health, Vydehi Hospital and Research Centere, Gunasheela
Hospital, Dr. Malathi Manipal Hospital for permitting me to conduct the study in their
institutions and for their cooperation throughout the study.
My sincere thanks to all the participants for their cooperation with out which the
study will be impossible.
I am very much grateful to my beloved Parents James Mathew and Lovely

James, sister Jikku James , for their support, constant encouragement, timely help and
inspiration which boosted up my morale during the course of this study.
It gives me great pleasure to express my heartfelt gratitude to my husband

Benil K Baby and family members for their valuable suggestions and encouragement.
Deepest thanks are extended to my classmates and friends for their inestimable
helps and inspiration rendered at every steps of the study.
VII
I owe a special thanks to nuns of Amal Jyothi Study House, Gottigere for their
prayer and support throughout the study period.
I would like to thank S K Enterprises, J P Nagar for their prompt service.
Finally I wish to acknowledge each and everyone who have directly and indirectly
helped me to complete this thesis successfully.
Date: Signature of the Candidate
Place: Jilu James.
VIII
LIST OF ABBREVIATIONS USED
Df Degrees of freedom.
NICU Neonatal intensive care unit
i.e That is.
NS Not Significant.
% Percentage.
SD Standard Deviation.
SPL Sound pressure level
db Decibel
KMC Kangaroo mother care
LBW Low birth weight
X2 Chi-Square.
SPL Sound pressure level
WHO World Health Organisation
IX
ABSTRACT
A study entitled “A study to assess the view of nurses regarding management of
environmental stress among High-risk newborn admitted in neonatal intensive care unit
(NICU) in selected hospitals, Bangalore with a view to develop an information booklet”
Background of the study
High-risk newborns and the babies who experience medical complication are
admitted to neonatal intensive care units, and each year over 40,000 babies are admitting
in NICU, as a worldwide. High-risk newborns are exposed to various forms of
technology, sounds, lightening and un-favorable setting of NICU. Infant’s sensory
experiences in the NICU to frequent stressful interventions exert harmful events on the
immature infants, that alerts its subsequent development. The physical and psychological
neonatal Intensive care unit (NICU) environment may be the single most important factor
in neonatal development. Frequent procedures, handling, and exposure to light and noise
may cause physiological stress on infants that increase their length of stay in the NICU
and ultimately decrease cognitive development. The neonatal intensive care unit (NICU)
can be a life-saving environment but may also cause long-term physical and psychosocial
complications. Consistent, excessive, loud noise in the NICU can increase neonates’ heart
rate, blood pressure, respiratory rate, decrease oxygen saturation and expose the infant to
higher cortisol levels and increased caloric expenditure.
Neonatal nurses are infant advocates, in providing holistic care, attention must be
given to the effect of the environment stimuli, on the physical and psychosocial
development of the infant. Nurses can take measures to create a soothing, quiet and calm
X
environment that is more conducive to healing, growth and development. Modifying the
physical environment of the NICU and holistic nursing care can minimize disturbances to
infants’ growth and development.
Objectives:
1. To assess the view of nurses regarding management of environmental stress
among High-risk newborn admitted in NICU.
2. To find out the association between the view of nurses regarding management of
environmental stress with selected demographic variables.
3. To develop and distribute an information booklet based on the findings.
A non-experimental, descriptive design was adopted; purposive sampling
technique was used to select 80 staff nurses on certain criteria. The data was gathered
using a structured interview schedule prepared by the investigator. Content validity of the
tool was obtained from experts of related departments. The reliability of the tool was
found to be r=0.92. Pilot study was conducted among 8 staff nurses with constructed tool
with which it was found reliable. The collected data were analyzed by using descriptive
and inferential statistics.
Results
Major findings of the study were
Findings revealed that the highest 54% of the nurses were in the age group of 21-
30 years, 82% were females, 62% were unmarried, 60% of them were GNM, 41% were
not having children, 36% were belongs to middle class, 38% were having more than 11
XI
years of working experience as a staff nurse, 41% were having less than 1 year of
working experience in NICU and finally 100% were not having previous exposure in
handling high risk newborn in family.
Findings revealed that majority of nurses in selected hospitals; overall aspect wise
the view of nurses were positive towards Signs & Management of Noise, Bright Light,
Positioning, Massage, Pain, Kangaroo mother care, Music therapy and followed by
Causes for environmental stress in NICU. However the view of nurses towards
Environmental stress and Neonatal intensive care unit & high risk newborn were neutral.
The result shows that 99 % of nurses have positive view; 1% of the nurses have
neutral view and none of them have negative view regarding management of
environmental stress among high risk newborn admitted in Neonatal Intensive Care Unit
(NICU).
It was inferred that majority of nurses, overall there is a positive view regarding
management of environmental stress among high risk newborn admitted in Neonatal
Intensive Care Unit (NICU).
The results shows that there is a significant association between the views of
nurses regarding management of environmental stress among high risk newborn admitted
in Neonatal Intensive Care Unit (NICU) and selected socio demographic factors such as
Age χ2= 62.87(s); Gender χ2= 89.93(s); Marital status χ2= 43.92(s); Professional
qualification χ2=81.99(s); Number of children χ2=49.62(s); Income per month χ2 =
34.62(s); Total years of working experience as a staff nurse χ2 = 30.87(s); Total years of
working experience in NICU χ2 = 47.49(s); and finally previous exposure in handling
high risk newborn in family χ2 = 76.00 (s) at 0.001 level.
XII
Therefore, it was inferred that the socio-demographic factors such as age,
gender, marital status, professional qualification, number of children, income per month,
total years of working experience as a staff nurse, total years of working experience
in NICU, Previous exposure in handling high risk newborn in family, shows there
is a significant association between the view of nurses and socio-demographic variables
(P > 0.001 level).
Interpretation and Conclusion
Findings of the study showed that majority of the staff nurses have positive view
regarding management of environmental stress among High-risk newborn admitted in
NICU. And the study result shows that, there is a significant association found between
knowledge score and selected demographic variables such as age, gender, marital status,
professional qualification number of children, income per month, total years of working
experience as a staff nurse, total years of working experience in NICU, previous exposure
in handling High-risk newborn in family.
Keywords
Nurses, Environmental stress, High-risk newborn, NICU, Information booklet.
XIII
TABLE OF CONTENTS
SL No. CONTENT PAGE No.
1 Introduction 1-8
2 Objectives 9-16
3 Review of Literature 17-38
4 Methodology 39-49
5 Results 50-84
6 Discussion 85-88
7 Conclusion 89-94
8 Summary 95-100
9 Bibliography 101-108
10 Annexure 109-131
XIV
LIST OF TABLES
TABLE PAGE
TITLE
No. No.
Percentage and frequency distribution of staff nurses by
1 personal characteristics. 53-54
2 Association between age and view of Nurses. 56
3 Association between gender and view of Nurses. 58
4 Association between marital status and view of Nurses. 60
5 Association between number of children and view of Nurses. 62
6 Association between income per month and view of Nurses 64
Association between professional qualification and view of

7 66
Nurses.
Association between the total years of working experience as

8 68
a staff nurse and View of Nurses.
Association between the total years of working experience in

9 70
NICU and view of Nurses.
Association between the previous exposure in handling High-

10 72
risk newborn in family and view of Nurses.
Distribution of overall view of nurses regarding management
11 of environmental stress among high risk newborn admitted in 73

Neonatal Intensive Care Unit (NICU).
XV
Distribution of view of nurses according to their aspect wise
12 related to Neonatal Intensive Care Unit (NICU) and High- 75

risk newborn.
13 76
related to Environmental Stress.

14 77
related to causes for environmental stress in NICU.

15 79
related to Signs.
16 related to management of noise, bright light, positioning, 80

massage, pain; kangaroo mother care, music therapy.
Mean standard deviation and range regarding view of nurses
17 regarding management of environmental stress among High- 83

risk newborn admitted in NICU.
XVI
LIST OF FIGURES
Sl. No. Figures Page No

Modified conceptual framework of King’s Goal attainment
1 theory.
16
2 Schematic representation of research study. 41

Bar diagram showing percentage distribution of respondents
3 according to age group.
55
Pie diagram showing percentage distribution of respondents
4 according to gender.
57
Pyramidal diagram showing percentage distribution of
5 respondents according to marital status.
59
Cylindrical diagram showing distribution of respondents
6 according to number of children.
61
Cone diagram showing distribution of respondents according to
7 income per month
63
Bar diagram showing distribution of respondents according to
8 professional qualification.
65
Pie diagram showing distribution of respondents according to
9 total years of working experience as a staff Nurse.
67
Cylindrical diagram showing distribution of respondents
10 according to total years of working experience in NICU
69
Bar diagram showing distribution of respondents according to
11 the previous exposure in handling High-risk newborn in family.
71
Bar diagram showing distribution of overall view of nurses
12 regarding management of environmental stress among High- 74

risk newborn admitted in NICU in selected hospitals.
XVII
LIST OF ANNEXURES
PAGE
SL No. ANNEXURE
No.
Letter seeking and granting permission to conduct research
1 study
110-114
Letter seeking expert’s opinion to establish content validity

2 of the tool and Information booklet.
114-115
3 Acceptance form for tool and Information booklet validation. 117
4 Content validation certificate. 118
5 Evaluation criteria checklist for validation of tool. 119
Evaluation criteria checklist for validation of Information

6 booklet.
120-121
7 Consent form – English. 122
8 Tool used for the study – English. 123-129
9 List of Validators. 130
10 List of formulas used. 131
XVIII
\ÇàÜÉwâvà|ÉÇ
I
1. INTRODUCTION
We ourselves feel that what we are doing is just a drop in the ocean,
But the ocean would be less because of that missing drop
-Mother Theresa
The Neonatal Intensive Care Unit (NICU) stress refers to the problematic adaptation
between newborn’s growth and developmental needs and the socio-physical
environment. (warren 2000)1.
Stress as an internal stimuli or pressure that challenge an individual ability to
adapt or cope2. Environmental stress for High-risk newborn in NICU includes, stimuli
such as pain, voices, noises, light, positioning and touch3. Every birth begins with a
complex period that enable adaptation to external world. Uterus is the normal
environment for a developing fetus between 23 to 40 weeks. Intra-uterine environment
protect the fetus in a dark and wet media that enables movement of and also surrounds
fetus with filtered sounds to protect it from external stimulations4.
High-risk newborn that leaves intrauterine media untimely faces a very different
environment and does various adjustments to adapt to it successfully. The physical and
psychological neonatal Intensive care unit (NICU) environment, is the most important
factor for the neonatal development4. Frequent procedures, handling, and exposure to
light and noise may cause physiological stress and also the baby is away from the sensual
pleasure, like touching, smelling, sucking from mother’s breast, voice of mother that
leads to psychological stress, ultimately decrease cognitive development5.
2
The NICU combines advanced technology and trained health care professionals to
provide specialized care for the tiniest patients. Excessive auditory stimulation may
impede the growth of infants and creates negative physiologic responses such as apnea
and fluctuations in heart rate, blood pressure, and oxygen saturation. The noise of the
incubator motor is 55-60 db and warmer bed is 62db, the average noise level should be
50 db6. High-risk newborn exposed to prolonged excessive noise are also at increased
risk for hearing loss, abnormal brain and sensory development, and speech and language
problems. Reducing noise levels in the NICU can improve the physiologic stability of
High-risk neonates and therefore enlarge the potential for infant brain development7.
Frequent handling of High-risk newborns may lead to physiologic and behavioral
stress, which is shown as tachycardia, bradycardia, tachypnoea, apnoea, desaturation,
colour changes to dusky or flushed, and responses like hiccups or yawning6.
Healthy term babies commonly response to stress by crying but the High-risk
babies may show different stress signs. Signs of stress seen in High-risk babies are;
feeling uncomfortable with eye contact, turning right and left, making hiccups,
grimacing, closing eyes, sticking tongue out, sneezing, coughing, yawing, gagging,
arching Hands on face or under chin8.
An extra-uterine environment such as neonatal intensive care unit causes
incompatibility between the psychobiological process of development and the sensual
stimulations experienced by babies. Intensive care unit environment, causes stresses,
which disturb the baby, and negatively affects the fragile physical condition of a baby
and the immature organ systems9.
3
A neonatal intensive care unit (NICU) nurse is supposed to get the education
special to this branch, she is supposed to be equipped with the knowledge needed to be
able to reduce the factors that lead to stress in newborns to the minimum9. NICU should
provide supportive, nurturing environment that will improve the developmental outcome
of hospitalized neonates8.
Nurses became core member of intensive care unit team for high standard
treatment and nursing care of newborns. Nursing care needs must be baby-cantered and
must be applied in the way that they support development of babies ‘’Individualized
Supportive Developmental Nursing Care’’ to bring environmental factors under control
and arrange them considering newborn’s individuality and behavioural organization10.
Need for the study
“Give your stress wings and let it fly away.”
[Terri Guillemets]
“The more immature the infant, the more vulnerable he or she is to the
environment they are exposed to”8. The immature infant does not have the developmental
capacity to endure environmental stresses the way a full term infant might.11 High risk
newborn who experienced early exposure to stress displayed decreased brain size,
functional connectivity, and abnormal motor behaviour11.
According to the Bulletin of the World Health Organization (WHO), as a
worldwide 9.6% of all birth are High-risk newborns, 60% experience environmental
stress in NICU, 5761 out of 69470 live births experiencing stress in NICU12.
4
NICU were developed in 1950s by paediatricians to provide better temperature
support, isolation from risk of infection, specialized feeding and access to specialized
equipments and resources13. Neonatal intensive care, along with rapid technology is
associated with improved survival for High-risk babies13.
Sophisticated equipments for the monitoring and maintenance of vital functions
and the availability of continuous laboratory supports are the essential of intensive care.
Equipments utilized for the care of sick newborn in the NICU are radiant warmers,
incubators, oxygen therapy and monitors, transcutaneous bilirubinometer, blood pressure
monitors, infusion pumps, ventilators, cranial ultra sonography and intra cranial pressure
monitor. Incubators provide a special environment for high risk babies till they adapt
themselves to standard nursery/home conditions14.
The survival of new born babies depends upon the availability of specially trained
nurses. Intensive care has created the need for highly skilled personnel trained in the art
of neonatal intensive care15. The National Council of India has not outlined any special
guidelines for this purpose. The National Neonatology Forum of India has recommended
that at least one trained nurse should be allocated to provide coverage to four babies in
the special care neonatal unit15.
Average daily exposure to stressors was greatest in the first 14 days following
birth. The greater number of stressors that an infant was exposed to was associated with
decreased frontal and parietal brain width16. The neurological development of babies can
be adversely affected by a number of factors surrounding the birth. Stress in the intensive
care unit, will affect the brain development of the newborn. They have found that early
5
exposure to stress can reduce the brain size and affect its proper functioning15. The
researchers found that exposure to stressors varies from baby to baby and also changes
during the course of the hospital stay for a particular baby, the maximum stress among
newborn during the first 14 days following the delivery16.
A study was conducted on Neonatal intensive care practices harmful to the
developing brain in KEM hospital, Pune. There has been a marked increase in the
survival of extremely low birth weight infants, but these babies have a long stay in
the NICU. Strategies to decrease their neuro developmental impairment become very
important. The maximum development of the brain occurs between 29-41 weeks. From
the warm, dark, acquatic econiche, where the baby hears pleasant sounds like the
mother's heart beat, the baby suddenly finds itself in the dry, cold, excessively bright,
noisy, environment of the NICU. Noise, bright light, painful procedures, and ill-timed care
giving activities, adversely affect the infant's development and cause stress. Excessive
radiation from X-rays of babies on the ventilator and CT scans also affect the brain.
Hence a developmentally supportive environment and humanized care will go a long way
in enhancing the developmental outcome of these babies.17
A study was conducted on spectral analysis of noise in NICU, in St. Johns
medical college, Bangalore. Objective was to perform spectral analysis of noise
generated by equipments and activities in a level III neonatal intensive care unit and
measures the real time sequential hourly noise levels over a 15 day period. Method used
was noise generated in the NICU by individual equipments and activities were recorded
with a digital spectral sound analyzer to perform spectral analysis over 0.5 - 8 KHz.
Sequential hourly noise level measurements in all the rooms of the NICU were done for
6
15 days using a digital sound pressure level meter. Result shows that the mean noise
levels in the ventilator room and stable room were 19.99 dB (A) sound pressure level
(SPL) and 11.81 dB (A) SPL higher than the maximum recommended of 50 dB (A)
respectively ( p < 0.001). The equipments generated 19.11 dB SPL higher than the
recommended norms in 1 - 8 KHz spectrum. The activities generated 21.49 dB SPL
higher than the recommended norms in 1 - 8 KHz spectrum ( p< 0.001). The ventilator
and nebulizers produced excess noise of 8.5 dB SPL at the 0.5 KHz spectrum. These
level warrant immediate implementation of noise reduction protocols as a standard of
care in NICU.18
Anatomical, functional and neurochemical maturation of pain pathways is well
developed in fetus and neonates19. Various physiological and behavioural responses to
painful stimuli in neonates substantiate their ability to feel pain. Pain expressions in the
newborn not only reflect tissue damage but are a function of ongoing behavioural state.
The ultimate aim should be to keep neonates free from pain and other stressful stimuli as
far as possible, by advocating minimal handling protocol, giving comforts after painful
procedures.19
The preterm infants who experience kangaroo care have improved cognitive
development, decreased stress levels, reduced pain responses, normalized growth, and
positive effects on motor development. Finally, kangaroo care helps to promote frequent
breastfeeding, and can enhance mother-infant bonding. 10
7
Intensive care unit environment, which disturb the baby, cause stress,
overstimulations and lack mother-father contact, negatively affects the fragile physical
condition of a baby and it’s immature organ systems.
For this reason, nurses working in neonatal intensive care units must;
1. Be good at communication.
2. Be experienced
3. Be able to solve problem reasonably and practically.
4. Be open-minded, have entrepreneurial spirit and must have good observation skills.20
A neonatal intensive care unit (NICU) nurse is supposed to get the education
special to this branch, and supposed to be equipped with the knowledge needed to be able
to reduce the factors that lead to stress in newborns to the minimum. In this way, stress
caused by environmental factors can be reduced to minimum within the process that takes
place in intensive care unit. For this reason, this research is made in an attempt to define
the methods used in nursing care to reduce the stress caused by environmental factors. As
per the above observation and studies, investigator feels that it is important to update the
view of nurses regarding the environmental stress and its management among newborn
admitted in NICU and the views of nurses and distribution of information booklet
will be an effective way to impart this knowledge. Hence investigator decided to
collect the views of nurses regarding the management of stress among the High-risk
newborn admitted in NICU and to develop and distribute an information booklet.
8
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9
2. OBJECTIVES
Research objectives are what the investigator proposes to accomplish in research.
That is specific measurable short term goals to be met21.
Statement of the problem
“A study to assess the view of nurses regarding management of environmental
stress among High-risk newborn admitted in Neonatal Intensive Care Unit (NICU) in
selected hospitals, Bangalore with a view to develop an information booklet”.
Objectives of the study
2. To find out the association between the view of nurses regarding management of
Hypothesis
H1: There will be a significant association between the view of nurses regarding
management of environmental stress among High-risk newborn and selected
demographic variables.
Operational definitions
1. Assess: It is the act to measure the nurses level of view, regarding management
of environmental stress among High-risk newborn admitted in NICU.
10
2. View: It refers to an opinion or belief about a particular situation or aspect.
3. Nurse: A nurse refers to those individual who have completed diploma or degree
in nursing and who can handle High-risk babies and caring the babies admitted in
NICU.
4. Environmental stress: It refers to a state of physiological (hypoxemia,
tachycardia, increased intra-cranial pressure) – behavioural (Sleep disturbance,
irritability, crying) imbalance resulting from the impact like noise, light, touch
and painful procedures in NICU.
5. High-risk newborn: It refers to any neonate, regardless of birth weight, size or
gestational age, who has a greater than average chance of morbidity or mortality,
especially within the first 28 days of life.
6. Neonatal Intensive Care Unit: It refers to a specialized unit which gives special
and emergency care to High-risk newborn who admitted in NICU.
7. Information booklet: It is a brochure consists of data, which includes definition
of environmental stress, causes, signs of stress, effects, and management of stress
among High- risk newborn.
Assumptions
The study assumes that,
1. Stressful environment may present in the NICU
11
2. Nurses may have some knowledge regarding management of environmental stress
among high risk newborn admitted in NICU.
Conceptual frame work
Conceptual Frame Work means interrelated concepts or abstractions that are
assembled together in some rational scheme by virtue of their relevance to a common
theme. A conceptual Frame Work is a group of concepts and set of proportions that spell
out the relationship between them. Conceptual framework plays several interrelated roles
in the progress of science. The overall purpose is to make scientific findings meaningful
and generalizable.22
The present study aimed at assessing the view of nurses regarding management of
environmental stress among high risk newborn admitted in Neonatal Intensive Care Unit
(NICU) in selected hospitals, Bangalore with a view to develop an information booklet”.
Conceptual framework based on King’s Goal attainment theory.
The conceptual model for the study is based on the Imogene King’s Goal
attainment theory. The theory explains different interactions and communication between
two people which will help in the growth and development of the people. Imogene
King’s theory provides a way of examining the interaction between two people. The two
persons performing their role in a given time, one person helps another. The person
communicates each other and exchange of information takes place. The exchange of
information generates the understanding and perception of problems. Once the problem is
perceived there is a need to interact and try to intervene. So that the perceived problems
12
and transaction between two people establishes. The interaction among the person brings
growth and development of the person in terms of their knowledge and practice.
Main concepts of King’s Goal attainment & its application to the present study.
Concepts included under this study
1. Role, Time:
The role refers to, a set of behaviours expected of person occupying a position in
a social system. In this study there are two person (Researcher, Staff Nurse) performing
their role in a given time. One person (researcher) helps the other one (Staff Nurse).
2. Interaction
Interaction is a process of perception and communication between person and
person. The interaction taken place between the researcher and staff nurse. The researcher
interacts with the staff nurse by administering the structured questionnaire regarding
management of environmental stress among high risk newborn admitted in NICU. The
aim of the interaction is to find out the view of staff nurses regarding the topic.
3. Perception
The perception refers to each person’s representation of reality. Here, after the
administration of the knowledge questionnaire, The researcher perceive the view of
nurses regarding management of environmental stress among high risk newborn admitted
in NICU, and understand the need of the nurses to gain knowledge on management of
environmental stress in NICU.
13
4. Transaction
After the perception of the need of the staff nurse, the researcher tries to
intervene. Thus the researcher frames the information booklet.
Concepts not under this study
5. Communication
Communication is a process of exchanging information from one person to
another. The researcher communicates with the staff nurses by giving information
booklet on management of environmental stress among high- risk newborn admitted in
NICU.
6. Growth and development
The information booklet may give insights to the staff nurses, and the nurses will
gain knowledge regarding management of environmental stress among high risk newborn
admitted in NICU. The staff nurses may get satisfaction which lead to goal attainment.
Among the staff nurses , growth and development may take place in terms of knowledge
and practice regarding management of environmental stress among high risk newborn
admitted in NICU.
In this study the subjects were, 80 staff nurses who are working in Vydehi
institute of medical science, Indira Gandhi institute of child health, Gunasheela hospital
and Dr. Malathi Manipal hospital. The knowledge questionnaire was administered
regarding management of environmental stress. Once the transaction in terms of
preparation of information booklet is framed, the further step, which is not included in the
14
study, is communicating the person by administering the information booklet and
reassessing the staff nurses to understand the gain in knowledge after giving the
information booklet. The information booklet may increase the knowledge level of the
staff nurses leading to satisfaction and goal attainment.
15
Time Time
Administration of structured questionnaire to

the staff nurses regarding management of
Interaction
environmental stress among High- risk newborn
in NICU.
Perception of view &need of the nurses to

be aware of management of environmental
Perception
stress among High- risk newborn in NICU.
Feedback
Transaction Prepare an information booklet
Introduce information booklet & Re-assessing Unsatisfied

Communication
their view
Gain positive view Negative view
Satisfied
Key
Area Under Purview
Goal attainment of the study
• Area Not Under Purview
Growth and development take place in of the study

terms of their knowledge management of
environmental stress among high risk
Figure 1: Modified Schematic representation of King’s goal attainment theory.
16
exä|xã by
_|àxÜtàâÜx
17
3. REVIEW OF LITERATURE
A literature review helps to lay foundation for a study and can also inspire new
research ideas. A literature review early in the report provides readers with a background
for understanding current knowledge on a topic and illuminates the significance of new
study.21
In the present study literature is reviewed under following headings: .
1. Review of literature related to management of environmental stress among
High- risk newborn in NICU.
2. Review of literature related to role of nurse in the management of environmental
stress among High- risk newborn in NICU.
3. Literature related to effectiveness of information booklet for nurses.
1.Review of literature related to management of environmental stress among
High- risk newborn in NICU.
A longitudinal survey study was conducted on efficacy of low protocols in
reducing noise levels in the NICU, in St. Johns Medical college hospital, Bangalore. The
aim was to examine the effectiveness and cost of implementing a noise reduction
protocol in a level III neonatal intensive care unit (NICU).Setting was tertiary level
NICU. The noise levels were measured sequentially every hour for 15days. Result shows
that-the noise levels in all the rooms of the NICU is 70 dB. Recommendation are the
extent of noise reduction in the rooms of the NICU- ventilator room by 6.54 dB isolation
room by 2.26 dB, pre-term room by 2.37 dB and extreme preterm room by 2.09 dB). The
18
high efficacy and affordability of noise reduction protocols will reduce stress level and
maintain a standard of care in neonatal intensive care units23.
A study was conducted on Effect of oil massage on growth and
neuro-behaviour in High-risk neonates, Delhi. Objective of the study was
to assess the effect of oil massage on growth and neuro behaviour in high-risk newborn
less than 1500 g. A randomized Controlled Trial in tertiary level neonatal unit.
Samples were Neonates with birth weight <1500 grams, and grouped in to three,
(a) massage with oil, (b) massage without oil and (c) no massage. Weight, length, head
circumference and triceps skin fold thickness and neuro behaviour were measured in the
three groups at regular intervals. Results shows that Weight gain in the oil massage group
(365.8 +/- 165.2g) was higher compared to the only massage group (290.0 +/- 150.2g)
and no massage group (285.0 +/- 170.4g). Neonatal neuro-behaviour stability is higher in
oil massage group. Oil application may have a potential to improve weight gain and
reduce stress among High-risk neonates24.
A study was conducted on evaluation of sound pressure level in NICU, in Armed
forces medical college Pune. Objective of the study was to assess the noise level in the
NICU and identification of noise sources. Method used was the Sound level meter -2231,
for measuring SPL. Result shows that average SPL in the NICU remain between 60-80
decibels. Maximum recorded SPL in the NICU was 102 decibels produced by falling of
katori. Recommendations include turning down volume of the alarms of various
instruments to the minimum, use of visual alarms instead of audible, keeping the working
instruments at appropriate distance from the neonate, gently closing the portholes of the
19
incubator, testing each new incoming equipments for SPL. Maintenance of noise level
will reduce stress among high –risk newborn.25
A study was conducted on Effects of combined use of non-nutritive sucking,
oral sucrose, and facilitated tucking on infant behavioural states across heel-stick
procedures, in Chandigarh. Objective was to compare the effectiveness of different
combinations of non-nutritive sucking (sucking), oral sucrose, and facilitated tucking
(tucking) with routine care on infants' behavioural state before, during, and after heel-
stick procedures. A convenience sample of 110 high-risk babies risk babies were
randomly assigned to five combinations of non-pharmacological treatments: sucking-
oral sucrose-tucking; sucking-oral sucrose; oral sucrose-tucking; sucking-tucking; and
routine care. Infant states, measured by a state-coding scheme, included quiet sleep,
active sleep, transition, quiet awake, active awake, and fussing or crying. Result shows
Infants receiving oral sucrose-tucking, sucking-oral sucrose, sucking-oral sucrose-tucking,
and sucking-tucking experienced (p<0.001), (p=0.008), (p=0.017), and (p=0.105) fewer
occurrences of fussing or crying, than those receiving routine. Treatment combinations of
sucking-oral sucrose-tucking and sucking-oral sucrose facilitates infants' sleep and reduce
stress26.
A study was conducted on assessing the impact of on preterm infant stress, in
Spanish. Objective was to assess the efficacy of Kangaroo Care (KC) in decreasing stress
in newborns of 29-34 weeks. Method used was Quasi-experimental pre-post without
control group of infants 29 to 34 weeks, in an incubator, the sample size was fifty-one
premature infants. The study variables selected were: clinical variables,
premature infant stress, which consisted of two variables: the physiological stress signal
20
and the behavioural stress response. The variables were collected at three different times:
basal stress, during KC and after KC completion, making a comparison analysis between
the basal stress and after KC. Result shows that O(2) saturation was 94.73% before KC
and 95.92% after the intervention. The heart rate (HR) ranged from 158.14 bpm (beats
per minute) before the KC to 151.47 bpm after it. KC is related to the decrease in the
occurrence of neonatal variables of stress, helping to organize motor and physiological
systems to achieve a state of tranquillity27.
A study was conducted on Combining kangaroo care and live harp music therapy
in the neonatal intensive care unit setting in Israel. Objective was to study the usefulness
of combining live harp music therapy and kangaroo care (KC) on short-term
physiological and behavioural parameters of preterm infants in the NICU setting. Sample
used in this study were infants born between 32 and 37 weeks of gestation, with normal
hearing. Mother-infant dyads were randomly assigned to KC and live harp music therapy
or to KC alone. Result shows that KC and live harp music therapy had a significantly
beneficial effect on infant anxiety score ( P < 0.01). KC combined with live harp music
therapy is more beneficial in reducing infant anxiety than KC alone28.
A study was conducted on Care to relieve pain-stress in High-risk newborn, in
Italy. Aim of the study was to assess non-pharmacological pain-prevention and relief
techniques in neonates who underwent vein draws compared to subjects without pricking
by sucking a pacifier. The average values of the physiological parameters at rest and
after pain stimuli and behavioural conditions were recorded. Result shows that the
maximum heart rate values, respiratory rate, and the maximum respiratory rate values
were founds on subjects that underwent vein draws compared to subjects without
21
pricking (p < 0.01). The behavioural parameters shows that crying seems significantly
related to the duration and number of venipunctures (p = 0.000). Results suggest that
limiting the number and duration of vein draws could help to reduce pain related stress29.
A study was conducted on a model of neuro-developmental risk and protection
for High-risk newborn, in Virginia. The purpose of this article is to introduce a model of
neuro-developmental risk and protection that explains the relationships among bio-
behavioural risks, environmental risks, and care giving behaviours that potentially
contribute to neuro-behavioural and cognitive outcomes. The environment that is not
always supportive of brain development and long-term developmental needs. The model
supports the premise that interventions focused on neuro protection during the neonatal
period have the potential to positively affect long-term developmental outcomes for
vulnerable very preterm infants. Finding ways to better understand the complex
relationships among NICU-based interventions and long-term outcomes are important to
guiding care giving practices in the NICU30.
A study was conducted on noise and high-risk infant in NICU, in Ireland, High-
risk infants in the NICU are often exposed to continuous loud noise and damaging effects
of noise on the preterm infant's development. Excessive auditory stimulation creates
negative physiologic responses such as apnea and fluctuations in heart rate, blood
pressure, and oxygen saturation. Preterm infants exposed to prolonged excessive noise
are also at increased risk for hearing loss, abnormal brain and sensory development, and
speech and language problems. Reducing noise levels in the NICU can improve the
physiologic stability of sick neonates and therefore enlarge the potential for infant brain
development. Recommendations include covering incubators with blankets, removing
22
noisy equipment from the incubator environment, implementing a quiet hour, educating
staff to raise awareness, and encouraging staff to limit conversation near infants31.
A study was conducted on Relationships between environmental stressors
and stress bio-behavioural responses of high-risk babies in NICU, in Taiwan. A repeated-
measures research design to examine research variables in one group of preterm infants.
Measurements of research variables were recorded 1 hour in the morning and 1 hour in
the afternoon and conducted over 2 days. A convenience sample of 37 preterm infants
was recruited from 2 medical centers in Taiwan. A total of 4164 observations were made
and recorded during the study. Result shows that there is a statistically
significant (P < .05) relationship between environmental stressors and changes in
physiological signals. There were also statistically significant (P < .05) relationships
between environmental stress and some specific stress behaviours. This is applicable to
neonatal clinical practice because it demonstrates the importance of recognizing the
preterm infant's biological stress responses to environmental stressors, allowing for early
interventions to reduce the possibility of more serious physiological or pathological
changes in the status of the preterm infant32.
A study was conducted on noise in the neonatal intensive care unit in
Pennsylvania. The purpose was to examine acoustic environment in (NICUs) and
perceived factors contributing to noise levels in these NICUs. A quantitative method was
used for sound-level data collection, and a qualitative method was utilized during
interviews with nurses to examine perceptions of factors contributing to noise. Ambient
sound levels, measured in decibels, were taken at 5-minute intervals over a 2-hour period
during both day and night shifts in a central location at each NICU. Result shows that the
23
mean sound levels in each NICU ranged from 53.9 dB to 60.6 dB, NICUs can implement
behavioural and structural changes that can decrease the sound levels in the NICU
environment and decrease the potential for exposure of patients to the harmful
physiological effects of increased sound levels33.
A study was conducted on therapeutic touch with preterm infants in USA.
Objective was to explore the nature of the use of TT with preterm infants. Qualitative
descriptive methods were used to discover knowledge about how TT is used
with preterm infants. Samples were registered nurses who practiced TT
with preterm infants for varying years of experience. Sampling technique was
Telephone/in-person interviews and written narratives provided the data describing
nurses' use of TT with preterm infants. Result shows that the infants' responses to TT
included reduced heart and respiratory rates, enhanced ability to rest, improved
coordination in sucking, swallowing, and breathing, and a greater ability to engage
with the environment. TT as an adjunct to facilitating preterm infants' physiological,
behavioural, energy field development, and well-being34.
A study was conducted on Mother-newborn contact, of kangaroo (skin-to-
skin) care, in Cleveland. Objective was to describe the type and percent time of
kangaroo care (skin-to-skin) or standard care (controls). Design used was Randomized
controlled trial with assignment by computerized minimization to kangaroo care (n = 48)
or control (n = 43). Samples used are preterm infants 32 to less than 37 weeks gestation
and their mothers. Results analysed based on four groups: assignment for infants in each
group to postpartum or NICU. For KC dyads, SS postpartum was 22.0%; Skin to skin
NICU was 7.5%. KC wrapped holding postpartum was 11.6%; NICU was 1.8%. For
24
control dyads, wrapped holding postpartum was 13.9%; NICU was 6.1%. Result shows
that hospital and social supports for families are needed to facilitate early initiation of
Skin to skin, prolonged periods of mother-infant Skin to skin contact that will reduce
stress35.
A study was conducted on Skin conductance as a measure of pain and stress in
hospitalised infant in Australia. Aim to evaluate changes in skin conductance in
hospitalised infants under different environmental conditions and during both painful and
non-painful procedures. Method used was Measurements of skin conductance activity
were made in infants under three different environmental temperature conditions during
the routine non-painful nursing procedure. Sample size was 21 infants on 43 separate
occasions. Result shows that during the heel lance procedure, skin conductance activity
significantly increased upon lance (p < 0.05) and remained elevated following completion
of the procedure. Skin conductance activity can be recommended as a clinically useful
indicator of pain and stress in neonates36.
A study was conducted on noise-sensor light alarm reduces noise in the newborn
intensive care unit in China. One-group pre-post test design was to evaluate sound
distribution and sudden peak noise frequencies and the associated events after using a
noise-sensor light alarm in a tertiary neonatal intensive care unit (NICU). The alarm is
activated as the sound level reaches>or=65 (dBA). The environmental sound level was
monitored continuously for a period of 1 week before and 1 month after using the alarm.
The mean sound level in the incubator is 58 dBA and radiant heated bed were 58dBA.
The percentage of observation time of sound levels<58 dBA increased by 28% in the
incubator and 4% at the radiant heated bed (p<0.001). The noise-sensor light alarm
25
effectively reduces sound level and episodes of SPN in the NICU. This may alleviate
stress of noise for newborns with critical illness37.
A study was conducted on the effect of infant massage on weight gain,
physiological and behavioural responses in premature infants in Korea. The purpose of
this study was to evaluate the premature infants' responses to infant massage. Method
used was equivalent control pre-test- post-test design. The sample was divided into two
groups of 13 infants with gestational age less than 36 weeks at birth, birth weight less
than 2000 g, and no congenital anomalies. The experimental group received the massage
intervention twice daily for 10 days. The data were collected for 10 minutes prior to and
10 minutes after the massage. The results of this study showed that massage therapy
might enhance optimal physiological responses and behavioural organization of
premature infants. Nursing staff in the NICU can use massage to promote the infant's
capability to respond positively to his environment and to provide developmental support
for healthy premature infants38.
A study was conducted on stress and phototherapy among newborn, in
Neonotology department, Rothko. Research has revealed that phototherapy is a
photodynamic stress and can induce lipid per oxidation. There is increasing evidence that
many severe diseases of the neonate are caused by oxidative injury and lipid per
oxidation. In the present communiqué, review the oxidative susceptibility of the neonate
and the evidence now available that phototherapy induces oxidative stress. Although
intensive phototherapy (up to 40 m watt/cm2/nm) has been reported to be increasingly
effective, a little caution, we believe is warranted, till more definite data in the human
neonate, help resolve the issue39.
26
2. Review of literature related to role of nurse in management of environmental
stress among High-risk newborn in NICU.
A study was conducted on experience with kangaroo mother care, in Government
medical college Chandigarh. Objective was to study the feasibility and acceptability of
Kangaroo mother care (KMC) on the low birth weight infants (LBWI) and to observe its
effect on the vital parameters of the babies by the health care workers. Samples were 135
babies who completed minimum of 4 hrs of KMC/day. Result shows that the O2
saturation improved by 2-3%, temperature (degrees C) 36.75 +/- 0.19 to 37.23 +/- 0.25,
respiration stabilized (p<0.05 for all) and heart rate dropped by 3-5 beats. No episodes of
hypothermia or apnea were observed during KMC. Benefits of KMC to reduce babies
stress behaviour and improve maternal confidence, Positive attitude observed on health
care workers40.
A study was conducted on massage and touch therapy in neonate, in Apollo
hospital Delhi. Method used was various oil –based preparation among the neonates.
Result shows that massage has several positive effect in terms of weight gain, enhanced
neuromotor development, better emotional handling, reduce stress behavior, reduced
mortality in hospitalized patients41.
A study was conducted on Maternal-Infant Interaction in the NICU as a
Mechanism for reducing the effects of allostatic load on Neurodevelopment in Premature
Infants, in USA. The purposes of this article are to explain the regulation of infant
neurobiological processes during interactions between mothers and infants. Result shows
that Positive maternal-infant interactions during NICU hospitalization and have the
27
potential to reduce neurologic deficits and maximize positive neuro developmental
outcomes in premature infants, nurses can empower mothers to overcome these stressors,
promote sensitive interactions with their infants, and facilitate neurodevelopment. It is
critically needed to develop and test nursing interventions directed at assisting mothers in
supporting optimal neurodevelopment for their infants42.
A study was conducted on an ounce of prevention: decreasing painful interventions
in the NICU, in California. Objective was to encourage, pain prevention in the NICU,
with a goal of creating a new "minimal-pain "NICU culture. Sample was the nurses
working in NICU. Intervention used as assessing the performance of procedures by
novice versus experienced NICU personnel, evaluating the use of umbilical lines and
peripherally inserted central catheters to reduce the frequency of peripheral punctures,
This article discusses the physiology of pain in the neonate, identifies adverse
outcomes related to repeated pain, and proposes practice changes that can prevent
unnecessary pain in neonatal care43.
A study was conducted on decreasing noise level in our NICU: The impact of
a noise awareness educational program, in Canada. The objective of this research was to
measure baseline noise level in an NICU, compare it to recommendations of international
bodies, and evaluate the impact of a noise awareness educational program. Method used
was means of hourly average noise levels in decibels (dB) were compared with the
recommendations and pre- and post intervention (P = .05). Result shows that Mean noise-
level pre intervention was significantly higher than recommended (58.15 Vs 45 dB; P <
0.001). After controlling for these variables, it was demonstrated that the noise level did
significantly decrease post intervention (6.33 Vs 5.42 dB per RN & 4.68 Vs 4.08 dB per
28
patient, P < .000).Although the efficacy of the program was significantly limited by an
increase in general activity, it raised staff awareness and had important effects reflected
by the significant decrease in mean noise level44.
A study was conducted on relationship between nurse care giving behaviour and
preterm infant responses during bathing, in Taiwan. The purpose of this study was to
explore the relationships between specific nurse care-giving behaviours and
preterm infant behavioural responses during bathing and to identify nurse behaviours
associated with infant 'stress.' Samples were the convenient samples of 24 preterm infants
and 12 nurses were recruited. A total of 120 baths were videotaped. Method used was the
coding schemes to measure Infant and nurse behaviours. Result shows the use of
'containment' and 'positional support will reduce the stress'. Recommendations are nurse
should interact with infant during care-giving procedures, nurses need to provide more
supportive care-giving behaviours especially 'position support' and 'containment' based
on the infant's needs, and avoid care-giving that may be too rough and occur too quickly
without attending the baby's stressful signals45.
A study was conducted on how the NICU environment sounds to a preterm infant
in USA. Objective was to assess the sound levels in the NICU. Method used was the A
descriptive study of nursery ambient sound levels and sound levels associated with
nursery equipment and care activities was conducted in a Level III NICU.
Measurements were obtained using a sound level meter. Result shows that room
sound levels were reduced; however sound levels associated with care giving, equipment,
and activities continue to be high. Sound levels continue to be a clinical challenge
29
for NICU nurses. This study suggests some modification of care practices and equipment
selection that could reduce sound levels46.
A study was conducted on implementing potentially better practices to support the
neurodevelopment of infants in the NICU, in USA. Objective was related to the physical
environment of the newborn intensive care unit (NICU) in order to optimize the neuro
developmental outcome of newborns. Design used was the evidence-based approach.
Result shows that the process of collaborative quality improvement is useful in
identifying ways to optimize the physical environment of the NICU to improve the neuro
developmental outcome of the neonate. Recommendations include tactile stimulation,
providing early exposure to mother's scent, minimizing exposure to noxious odors,
developing a system for noise assessment of the NICU acoustic environment, minimizing
ambient noise in the infants environment, and preservation of sleep47.
A study was conducted on Sound level exposure of High-risk infants in different
environmental conditions. Objective was to provide descriptive information about the
sound levels to which high-risk infants are exposed in various actual environmental
conditions in the NICU. Descriptive and comparative designs, Convenience sample of
134 infants were selected. Result shows that the renovated NICU was, on average, 4-6
dBA quieter across all environmental conditions than a comparable non renovated room,
representing a significant sound level reduction.. Recommendation include Evidence-
based sound-reducing strategies are proposed. Findings were used to plan environment
management as part of a developmental, family-cantered care, performance improvement
program and in new NICU planning environmental interventions for care of the infants 48.
30
A study was conducted on room for improvement: nurses' perceptions of
providing care in a single room newborn intensive care setting, in USA. This article
reports the perceptions of 127 neonatal intensive care nurses after the move into a single
room neonatal intensive care unit (NICU). The observations of the nurses were obtained
using a questionnaire. The results suggest that the success of single room care model
primarily depends on providing sufficient staff coverage, given the decreased patient
visibility and greater distances between patients. Noise levels decreased from an average
of 63 to 56 decibels and catheter-associated bloodstream infections fell from 10.1 per
1000 device days to 3.3 per 1000 device days in the 9 months after the move to single
patient rooms.. Single patient room newborn intensive care units are designed to optimize
the developmental outcomes of critically ill infants by providing individual patient
environments with decreased stimulation and noise49.
A study was conducted on Staff attitudes and expectations about music therapy:
neonatal intensive care unit. A cross-sectional survey of NICU staff was performed and
eligible subjects were 187 NICU staff members. Surveys were distributed by e-mail, in
person, and in staff mail boxes. Data were analyzed using simple descriptive statistics,
The response rate was 75% Staff in NICU, most agreed that music enjoyed by patients
could reduce stress (86% in the NICU) and improve sleep (79% in the NICU)50.
A study was conducted on Nurses' beliefs and values about doing cue-based care
in an NICU in Taiwan. Objective was to assess how the care giving activities can reduce
stress among newborns. A qualitative research method and ten groups of questions
explore how NICU nurses take care of premature infants, nurses' perspectives on cue-
based care, and the extent to which NICU nurses practice cue-based care. The results
31
generated three themes: (1) timely and skilful management of the preterm infants;
(2) compassionate and holistic care for the infants and their highly stressed families; and
(3) the relationship between good nursing care and meeting the needs of preterm infants,
families, physicians, units, and the environment. The results have prompted changes in
care giving practices, attempting to reduce stress and strengthen protection for the infants,
in order to promote their stability and development in the neonatal intensive care unit
(NICU). To improve the quality of nursing care and preterm infant outcomes, it will be
necessary to educate NICU nurses on cue-based care, to enhance collaboration among all
team members, to reduce their non-nursing workload, and to re-design NICUs for optimal
cue-based care51.
A study was conducted on attitudes and expectations about music therapy for
High-risk infants among staff in a neonatal intensive care unit, in USA. Objective was to
assess how the music reduce stress in premature infants, Method used was the Cross
sectional survey, Result shows that the response rate was 75% and NICU staff holds
favourable attitudes toward music for premature infants. Music's effects on caregiver
attitudes, mood and behaviour may contribute to its impact on infants. Evaluation of the
effects of music on infants needs to account for caregiver's expectations and behaviour as
well as direct effects on infants' physiology52.
A study was conducted on the relationship between physiological and behavioural
measures of stress in high-risk babies. The purpose of this exploratory descriptive
analysis was to explore relationships among physiological stress, behavioural stress, and
motor activity cues in high-risk babies. Samples and sampling was the convenience
sample included 42 preterm infants who had been 27 to 33 weeks gestational age.
32
Measures used were in each 10-minute observation, heart rate (HR) and oxygen
saturation (O2 sat) levels were recorded every 5 seconds, and observational measures of
behavioural distress and motor activity were recorded twice a minute. Result shows that
Stress cues and motor activity were more often related to low levels of O2 sat than to low
or high HR. Recommendations, they suggest that neonatal nurses should monitor high-
risk babies' behavioural stress and motor activity cues in response to care giving and
minimize stimuli that evoke stress responses linked to physiological instability53.
A study was conducted on assessment of neonatal nurses' behaviours that
prevent overstimulation in High -risk babies, in Canada. Objective was to assessed the
adoption by neonatal nurses of behaviours that prevent overstimulations. The
convenience sample consisted of 54 neonatal nurses, a multiple-choice questionnaire, was
used for data collection. The results revealed that the nurses often adopted behaviours
that prevented tactile overstimulation, and that their intentions, attitudes, and subjective
norms all favored the adoption of such behaviours. Findings suggest that neonatal nurses
lack specific knowledge in this area and that they would benefit from the completion of
an evidence-based educational program on the prevention of overstimulation of preterm
infants prior to their employment in a Neonatal Intensive Care Unit (NICU)54.
A study was conducted on Neuro-developmental care in NICU. The intervention
undertaken to improve neuro-developmental outcome, includes NICU design, nursing
routines, nursing care plans, management of pain, feeding methods and, most
importantly, encouraging parental involvement with their NICU infant.
Pain management includes benign interventions (eg. non-nutritive sucking, oral glucose)
but the prolonged use of narcotics must be balanced against the consequences of sedation
33
and dependency. Kangaroo care, which involves parent/infant skin-to-skin contact,
improves preterm growth, decreases nosocromial infections and may shorten hospital
length of stay. A great deal of work needs to be done to identify and demonstrate efficacy
of specific interventions and changes that humanize the NICU, encourage parental
involvement, support infant development and optimize preterm neuro-developmental
outcomes55.
A study was conducted on Neonatal nurse response to control of noise inside the
incubator. The purpose of this study was to test the effect of acoustical foam on the level
of noise inside the incubator and examine neonatal response behaviours to changes in
environmental noise. Sound levels, oxygen saturation, and infant states were measured
and recorded during three study conditions: pre-study neonate in incubator, neonate in
incubator with 5 x 5 x 1 inch acoustical foam pieces placed in each of four corners, and
post-study recovery of neonate in incubator with foam removed. The findings
demonstrate a significant treatment effect of acoustical foam on decreasing
environmental noise measurements inside the incubator (p =0.006). Findings also
demonstrate significantly changed neonatal state response behaviours with decreasing
environmental noise measurements inside the incubator (p = 0.00). There was a
significant correlation between higher noise levels and oxygen support therapy; the
findings suggest that special nursing considerations should be taken when caring for
ventilator-dependent infants. Noise control protocols should focus on essential
environmental interventions for care of the infants56.
A study was conducted on an NICU infant stress reduction QI team, in USA.
Objective was to assess the nursing care strategies designed to support the normal
34
development of premature infants, QI team set out to recommend changes in patient care
which would reduce newborns' stress in the NICU. Changes in care required negotiations
with the physicians and directors of affected departments, extensive rewriting of policies,
clinical evaluations, requests of additional supplies, and comprehensive staff training.
Changes were made in the NICU environment (for example, light and noise
reductions).Result shows that redesigning procedures and care protocols could reduce
the stress of the patients in the NICU57.
A study was conducted on Excessive noise levels in the neonatal ICU: potential
effects on auditory system development. Objective was to asesss exceedingly high noise
levels in the neonatal intensive care unit (NICU) and in incubators. Method used was a
noise level meter was used to evaluate ambient noise levels in three rooms of the NICU
and to compare those levels with measurements taken inside an occupied incubator.
Result Mean hourly noise levels measured inside the incubator (61 dB) were significantly
higher than those measured outside (55 dB). Ambient noise levels were also significantly
higher in rooms where staff activity was greatest (59dB). In addition, peak noise levels in
excess of 120 dB were found. Staff activity is a significant contributor, so intervention
strategies are recommended58.
A study was conducted on effects of handling procedures on pain responses of
very low birth weight infants, in Sharjah. The purpose of this study was to investigate the
effects of handling on pain responses of infants with very low birth weight (VLBW).
Method used was eighteen infants with VLBW were observed for two-hour periods.
Infants' pain responses were recorded using the Neonatal Inventory Pain Scale before and
after each handling episode. Twelve infants were observed once, six were observed
35
twice. Result shows that Pain scores were significantly greater after handling. During a
24-hour period, infants were handled an average of 53 times for an average of 2.7 hours.
Handling infants with VLBW significantly alters their pain responses.. The results have
implications for the training of neonatal caregivers59.
A study was conducted on Frontal brain activation in premature infants' response
to auditory stimuli in neonatal intensive care unit, in Japan, aim was to examined whether
they can discriminate between their mothers' utterances and those of female nurses in
terms of the emotional bonding that is facilitated by prosodic utterances. Result showed
that the premature infants reacted differently to the different voice stimuli. Therefore, we
presume that both mothers' and nurses' voices represent positive stimuli
for premature infants because both activate the frontal brain, but must also address the
stressful trigger of nurses' voices for NICU infants60.
3. Review of literature related to information booklet for nurses.
A Study was conducted on the effectiveness of an information booklet on care of
a low birth weight baby administered to nurse in St. John’s Medical College Hospital,
Bangalore. The research approach used for this study was evaluative research approach.
Data was collected from 60 nurses who were selected purposively, of which data from
only 41 were analyzed. Result shows that no significant correlation was found between
baseline variables and knowledge (pre-test scores, post-test scores or gain in scores) of
either control or experimental group. This indicated that the information booklet probably
would have enhanced the knowledge and practice61.
36
A study was conducted on effect of using an interactive booklet about childhood
respiratory tract infections in primary care consultations on reconciling and antibiotic
prescribing, in UK. Intervention group (health worker) were trained in the use of an
interactive booklet on respiratory tract infection. Result shows that reconsultation
occurred in 12.9% of children in the intervention group and 16.2% in the control group
(absolute risk reduction 3.3%, 95% confidence interval −2.7% to 9.3%, P=0.29). Use of a
booklet on respiratory tract infections in children within primary care consultations led to
important reductions in antibiotic prescribing and reduced intention to consult without
reducing satisfaction with care62.
A study was conducted 0n effectiveness of newborn care Information Booklet
enhancing nurses knowledge in Hyderabad. Aim was to assess the level of knowledge
about newborn care among nurses working in NICU. Method used a self administered
structured questionnaire and also to assess the effectiveness of information booklet
designed on various aspects of newborn care on their knowledge. Sample used to select,
nurses by using the non probability purposive sampling technique. Result shows that: The
post test scores were significantly higher than the pre-test knowledge scores, which
indicate that the developed information booklet regarding newborn care was highly
effective in enhancing the knowledge levels of the nurses. The information booklet was
effective in enriching the knowledge of nurses on newborn care63.
A study was conducted on measuring preterm cumulative stressors within
the NICU: the Neonatal Infant Stressor Scale preterm infants, in Mousberian. Aim was to
quantify the severity of common stressors for preterm infants with a view to providing a
tool to manage presumed accumulated infant stress. Method and subject were Seventeen
37
doctors and 130 nurses who work in Neonatal Intensive and Special Care Nurseries rated
the perceived stress severity of 44 acute events and 24 chronic living conditions for
preterm infants at three ages (<28 weeks, 28-32 weeks. Acute items (such as heel lance)
were organised into nursing, peripheral venous access, peripheral arterial access, central
vascular access, ventilation, nutrition, medical procedures, surgery, radiology and
miscellaneous categories. Chronic living conditions included items such as receiving
intranasal oxygen and having a systemic infection. Result shows that Doctors
and nurses perceived nearly all items to be stressful to infants to some degree and to be
equally stressful across ages. The degree of stress experienced by clinicians themselves
was generally low and moderately correlated with presumed infant stress for the same
items. Based on these results we developed the Neonatal Infant Stressor Scale to help
track, measure and manage presumed accumulated stress in preterm neonates64.
A study was conducted on the effectiveness of information booklet for staff
nurses regarding management of preterm babies. Methods-The study involved one group
pre test post test without a control group using quasi experimental design with purposive
sampling technique. A structured questionnaire was administered to 50 staff nurses along
with observations made using check list. This was followed by administration of
information booklet and post test was given after 8 days using the same questionnaire and
check list to find out the effectiveness. The results were described by using descriptive
and inferential statistics. Results findings related to effectiveness of information booklet
showed that the overall mean knowledge score in a pre test is 63.8% and 82.6% in the
post test. The overall mean practice score in a pre test is 52.0% and 70.6% in the post
test65.
38
`xà{ÉwÉÄÉzç
39
4. METHODOLOGY
Introduction
According to Polit and Beck, Research methodology is the techniques used to
structure a study and to gather and analyze information in a systematic way66. The role of
methodology consists of procedures and techniques for conducting study. The study
aimed to assess the nurse’s view regarding the management of environmental stress
Research approach
Research approach is the most significant part of any research. The appropriate
choice of the research approach depends upon the purpose of the research study, which
has been undertaken. A cross sectional survey research approach was considered the best
to assess the nurse’s view regarding management of environmental stress among High-
risk newborn admitted in Neonatal intensive care unit.
Research design
Researchers overall plan for obtaining answers to the research questions or for
testing the research hypothesis is referred to as the research design66.The investigator
selected non-experimental descriptive design to assess the nurses view regarding
management of environmental stress among High- risk newborn admitted in Neonatal
intensive care unit.
40
The research design is represented in following figure.
Aim- View of nurse’s regarding management of environmental stress among High- risk
newborn admitted in Neonatal intensive care unit
Research design- Non-Experimental Descriptive survey Design
Research setting - Selected hospitals, Bangalore.
Target population- Staff nurses who are working and having

experience in Neonatal intensive care unit.
Sample size- 80 staff nurses
Sampling technique- Non-probability purposive sampling
Instrument for data collection- Structured interview schedule
Data analysis and interpretation -Descriptive and inferential statistics
Findings
Reports
Figure 2 Schematic representation of Research Study
41
Variable: Qualities, properties, or characteristics of a person, things, and situations, that
change, may vary and are manipulated or measured in research66.
• Study variable: In this study, the study variable refers to the view of nurses
regarding management of environmental stress among High- risk newborn
admitted in NICU.
• Extraneous variables: Demographic variable are the factors which are not the
part of the study, but may affect the measurement of the study variables67. In the
present study it refers to the selected demographic variables such as age, gender,
Marital status, number of children, total years of working experience as a staff
nurse, total years of working experience in NICU, income, professional
qualification, previous exposure in handling High- risk newborn.
Setting of the study
Setting is the location for conducting research; it can be natural, partially
controlled, or highly controlled1.
In this study four hospitals were chosen for data collection namely Indiragandhi
institute of child health, Vydehi Institute of medical science and research centre situated
35 km away from the institute, Dr. Malathi Manipal hospital, Gunasheela hospital
situated 30 km away from the institute.
Population of the study: The population is the aggregation of all units in which a
researcher is interested or the population is the set of people or entities to which the
results of a researcher are to be generalized67.
42
The target population in the present study includes staff nurses who have
experience in Neonatal intensive care unit.
Sample and sample size
Sample may be defined as the representative unit of a target population which is
to be worked upon by researcher during their study1. Sample size is 80 staff nurses who
fulfil at the required characteristics of population. 30 staff nurses from Indiragandhi
institute of child health, 20 staff nurses from Vydehi institute of medical science and
research institute,20 staff nurses from Dr. Malathi Manipal hospital,10 staff nurses from
Gunasheela hospital, Bangalore.
Sampling Technique
Sampling technique is the process of selecting a group of people to conduct a
study. In this study, purposive sampling technique was adopted.
Purposive sampling is a type of non- probability sampling. Non probability
sample are selected on the basis of judgment of the researcher to achieve particular
objectives of the research66.
Criteria for sample selection
Inclusion criteria
• Nurses who have experience in neonatal intensive care unit.
• Nurses who are having educational qualification diploma and degree/ graduation.
43
Exclusion criteria
• Nurses who are not willing to participate.
• Nurses who are not present at the time of data collection.
Instrument used for the study
A structured interview schedule was used, which consists of two parts.
Section A: It consists of socio-demographic variable of the staff Nurse
Section B: Statements, it consists of structured interview closed ended statements
to assess the view of nurses regarding management of environmental stress among High-
risk newborn admitted in NICU.
Development and description of tool
The following steps were used in developing a structured interview schedule.
Review of literature
Consultation with guide and subject experts
Establishment of validity and reliability.
Review of literature
Books, journals, periodicals, published research studies were reviewed for
description of tool.
Preparation of tool: The instrument used in this study was structured interview
schedule. It comprises of two sections.
44
Section A:
Consist of 9 items related to socio-demographic variable of subjects such as age,
gender, marital status, number of children, total years of working experience as a staff
nurse, total years of working experience in NICU, income, professional qualification,
previous exposure in handling High- risk newborn.
Section B:
Structured interview schedule consisted of 46 items on management of
environmental stress among High- risk newborn admitted in NICU. General question
about environmental stress in NICU (8 statements), causes for environmental stress in
NICU(12 statements), signs of environmental stress in High-risk newborn (3statements),
management of environmental stress (22 statements). Annexure - VII
There are 46 items- positive and negative statements, 5 point scale were used to
rate the views, for positive score (5-1 rating) and negative score (1-5 rating).
Scoring key
ITEMS SCORE
1, 3, 5, 6, 7, 8 ,9, 10,
13,14,16, 17, 18, 19,
20,21,23,24,25,27,28, 5-1 POSITIVE SCORE
29,30, 31, 32,33, 34, 35
36, 37, 38, 39, 40, 41,42,
43,45,46.
2,4, 11, 12, 15,22, 26, 44 1-5 NEGATIVE SCORE
45
Testing of tool
Content validity: According to psychological foundation; validity is the
appropriateness, meaningfulness, and usefulness of the interference, made from the
scoring of the instrument67. Content validity of instrument was established by panel of
experts comprising paediatric nurses, neonatologist. The experts were requested to give
their opinions and suggestions regarding the relevance of tool for further modification of
items. Their experts comments and suggestions were incorporated in designing the final
tool for the study in consultation with guide and statistician for finalization of the tool.
Reliability of the tool: According to Talbot, Reliability of research instrument is
defined as the ability of the instrument to create reproductive results; it is the absence of
errors in measurement. It is then concerned with consistency, accuracy, precision,
stability, equivalence and homogeneity67. The structured interview schedule was tested
for reliability. 8 staff nurses were tested by using the tool. Reliability of the tool was
computed by using Karl’s Pearson split half method, tool was first divided in to two
equivalent halves. Where r = correlation coefficient computed on split halves. Co-
efficient correlation was found (r=.94) in which tool was found reliable for the study.
Development of information booklet
• Development of objective
• Consultation with experts
• Preparation of first draft of the content
• Content validation of information booklet
• Preparation of first draft of the content
46
Preparation of first draft of information booklet
To fulfil the research objective, an information booklet was formed on
management of environmental stress among High- risk newborn admitted in NICU. The
content covered were the introduction to environmental stress, causes, common signs,
and the management.
Preparation of the final draft of the information booklet
The final draft of information booklet is prepared by reviewing the correction,
opinion from the subject experts.
Pilot study
After having obtained formal administrative approval from the higher authorities
of Rama Krishna hospital, Jayanagar, Bangalore. A Pilot testing with 8 samples was done
on 1-10-12. The final set of questionnaire was prepared and deficiencies were found
during the pilot study.
Samples selected for pilot study were excluded in the actual study. On the day, 8
staff nurses were studied with a structured interview schedule. The investigator did not
face any significant problems and found the study to be feasible. The language and
comprehension of the tool was found to be clear and all the items in tool were clearly
understood by the subjects without ambiguity. Hence the tool was found to be reliable
and practicable for the study.
47
Procedure for data collection:
A formal written permission was obtained from concerned authorities of selected
hospital to conduct the study in the hospital setting. The staff nurses were consulted and
oral consent was taken from them. Each day, at the beginning of data collection, the
investigator met the nursing director and proceeds to respective departments for data
collection. The data was collected by using the structured interview schedule from 1st
November to 30th November. Before data collection, the purpose of the study was
explained to the respondents with self introduction. The data collection took an average
time of 30-35 minutes. Giving thanks to the participants, the data collection procedure
was terminated.
Plan for data analysis
The data obtained was analyzed on the basis of objectives and assumption of the
study. The data obtained was analyzed by using the descriptive and inferential statistical
tests.
The data analysis plan was as follows
• Organizing the data in a master sheet and Microsoft excel sheet
• Computation of frequencies and percentage
• Use of descriptive and inferential statistics
a)Descriptive statistics:
It deals with the enumeration, organization and graphical representation of data. It
is used to organize and summarize the data to draw meaningful interpretations1.
48
b) Inferential statistics:-
It provides the procedure to draw an inference about the condition that exists in a
large set of observations. It concerned with the population and use sample data to make
an inference about population or to test the hypothesis66.
Data was analyzed using descriptive and inferential statistics. Frequencies and
percentages are used to analyze the demographic features of staff nurses. Mean, standard
deviation and mean percentage will be used to describe the knowledge of the staff nurses.
The chi-square test is used to find the association between selected demographic
variables and view of staff nurses regarding management of environmental stress among
High- risk newborn admitted in NICU. Data will be presented in tables, graphs, and
diagrams.
Projected outcome:
The findings will reveal less exposure to particular topics in management of
environmental stress among High- risk newborn in NICU, which will be a guide for the
preparation of information booklet.
Summary:
This chapter dealt with research methodology adopted for the study. It includes
research approach, research design, population, sample, sampling technique, and research
setting, plan for development of tool and Information booklet, pilot study, data collection
procedure and plan for data analysis. The analysis and interpretation of the results have
been presented in following chapter.
49
exáâÄàá
50
5. RESULTS
The description of results is the heart of a research project. It is the
communication of facts, measurements and observations gathered by the researcher. For
achieving the research results, the collected data must be processed and analyzed in an
orderly coherent fashion.
Analysis refers to the computation of certain measures along with researching for
the pattern of relationship that exists among data groups.68
This chapter deals with the computation of certain measures along with searching
for patterns of relationship that exist among data group .Thus, in the process of analysis
relationships or differences supporting or conflicting with original or new hypothesis
should be subjected to statistical tests of significance to determine with what validity data
can be said to indicate any conclusions .
The data was collected from 80 nurses in selected hospitals, Bangalore, using a
structured questionnaire regarding management of environmental stress among High- risk
newborn admitted in Neonatal Intensive Care Unit (NICU).
The collected information was organized, tabulated, analyzed and interpreted
using descriptive and inferential statistics.
Objectives of the study:
among High- risk newborn admitted in NICU.
51
2. To find out the association between view of nurses regarding management of
Hypothesis of the study: H1: There will be a significant association between the view of
nurses regarding management of environmental stress among High-risk newborn and
selected demographic variables.
Organization of the study findings
Presentation of Data
The analysis data has been organized and presented in the following sections:
Part I: Percentage distribution of socio-demographic variables of nurses in selected
hospitals, Bangalore.
Part II: Data shows the association between nurse’s knowledge scores regarding
Intensive Care Unit (NICU) and selected Socio-demographic variables.
Part III: Distribution of overall nurse’s knowledge level regarding management of
environmental stress among High- risk newborn admitted in Neonatal Intensive Care
Unit (NICU).
Part IV: Distribution of aspect wise assessment of view of nurses regarding management
of environmental stress among High- risk newborn admitted in Neonatal Intensive Care
Unit (NICU).
52
Part V: Mean and Standard deviation of different sections of nurses view regarding
Part I: Percentage and frequency distribution of socio-demographic variables of
nurses in selected hospitals, Bangalore.
Sl No Variables Frequency(f) Percentage (%)

1 Age in years
21 - 30 years 43 54
31 - 40 years 17 21
41 - 50 years 14 18
51 - 60 years 6 7
2 Gender
Male 14 18
Female 66 82
3 Marital Status
Married 30 38
Un Married 50 62
Widow/Widower 0 0
Separated/Divorce 0 0
4 No. of Children’s
One 7 8
Two 30 38
Above Tow 10 13
No Child 33 41
53
5 Income/ month (Rs.)
Less than 7,000/- 26 33
7,001 – 10,000/- 29 36
10,001 – 13,000/- 7 9
Above 13,000/- 18 22
6 Professional Qualification
General nursing and

48 60
midwifery
Post basic nursing 15 19
Bachelor of science in
11 14
nursing
Master of science in
6 7
nursing
7 Total Years Of Working Experience as Staff Nurse
Less than 1 Year 17 21

1-5 Year 23 29
6-10 Year 10 12
Above 11 Year 30 38
8 Total Years Of Working Experience In NICU
Less than 1 Year 33 41

1-5 Years 28 35
6-10 Years 14 18
Above 11 Years 5 6
9 Previous Exposure To Handle High-Risk Newborn In Family
Yes 0 0
No 8 100
54
1. Distribution of respondents according to Age
Figure 3: Bar diagram depicting percentage distribution of respondents according to age

group.
INTERPRETATION:
Bar diagram shows that 54 % of the respondents were between the age group of
21-30 years; 21 % of the respondents were between the age group of 31-40 years; 18 %
of the respondents were between the age group of 41-50 years; and finally 7% of the
respondents were in the age group of 51 – 60 yrs. It was inferred that majority of nurses
were in the age group of 21 to 30 years.
55
Table 2. Association between Age and view of Nurses
N = 80
Negative Neutral View Positive View Total

Age View χ2
( 1 – 77) ( 78 – 154) (155 – 230)
(in yrs)
N % N % N % N %
21– 30 yrs
- - 1 100.0 42 53.0 43 54.0
31– 40 yrs
- - - - 17 21.0 17 21.0 62.87
significant
41– 50 yrs
- - - - 14 18.0 14 18.0 0.001
level
51- 60 yrs
- - - - 6 8.0 6 7.0
Total
- - 1 100.0 79 100.0 80 100.0
Calculated χ2 value is 62.87, table value is 22.46 at 0.001 level of significance.
The calculated value is greater than the table value. Hence, research hypothesis is
accepted. It shows that there is a significant association between the age and nurses view
regarding management of environmental stress among High- risk newborn admitted in
Neonatal Intensive Care Unit (NICU).
56
2. Distribution of respondents according to Gender
Figure 4: Pie diagram depicting percentage distribution of respondents according to
gender.
INTERPRETATION:
Pie diagram shows that 18% of the respondents were males and 82% of the
respondents were females. It was inferred that majority of nurses were females.
57
Table 3. Association between Gender and view of Nurses
N=80
Negative View Neutral View Positive View Total
Gender ( 1 – 77) ( 78 – 154) (155 – 230) χ2
N % N % N % N %
Male - - 1 100.0 13 16.0 14 18

89.93
.001 level
Female - - - - 66 84.0 66 82
(Significant)
100.
Total - - 1 100.0 79 100.0 80
0
accepted. It shows that there is a significant association between the gender and nurses
view regarding management of environmental stress among High- risk newborn admitted
in Neonatal Intensive Care Unit (NICU).
58
3. Distribution of respondents according to marital status
Figure 5: Pyramidal diagram depicting percentage distribution of respondents according
to marital status.
INTERPRETATION:
Pyramidal diagram shows that 38% of the respondents were married; 62% of the
respondents’ were unmarried, none of the respondents were widow/widower and
divorce/separated. It was inferred that majority of nurses were unmarried.
59
Table 4. Association between Marital status and view of Nurses
N = 80
Negative Neutral Positive Total
Marital View View View

χ2
status ( 1 – 77) ( 78 – 154) (155 – 230)
N % N % N % N %
Married - - - - 30 38.0 30 38.0
Unmarried - - 1 100.0 49 62.0 50 62.0

43..92
Widow/
significant
- - 0 0.00 0 0.00 0 00.0
widower
0.001 level
Divorce/
- - 0 0.00 0 0.00 0 00.0
separated
Total - - 1 100.0 79 100.0 80 100.0
accepted. It shows that there is a significant association between the marital status and
nurse’s view regarding management of environmental stress among High- risk newborn
admitted in Neonatal Intensive Care Unit (NICU).
60
4. Distribution of respondents according to number of children
Figure 6: Cylindrical diagram depicting percentage distribution of respondents according
to number of children
INTERPRETATION:
Cylindrical diagram shows that 8% of the respondents were having one child;
38% of the respondents were having two children; 13% of the respondents were having
above two children and finally 41% were not having children. It was inferred that
majority of nurses were not having children.
61
Table 5. Association between number of children and view of Nurses
N = 80

Number of View View View χ2
children ( 1 – 77) ( 78 – 154) (155 – 230)
N % N % N % N %
One - - - - 7 9.0 7 8.0
Two - - - - 30 38.0 30 38.0 49.62
significant
Above two - - - - 10 12.0 10 13.0
0.001
level
No children - - 1 100.0 32 41.0 33 41.0
Total - - 1 100.0 79 100.0 80 100.0
accepted. It shows that there is a significant association between number of children and
nurses view regarding management of environmental stress among High- risk newborn
admitted in Neonatal Intensive Care Unit (NICU).
62
5. Distribution of respondents according to income per month
Figure 7: Cone diagram depicting percentage distribution of respondents according to
income per month.
INTERPRETATION:
Cone diagram shows that 33% of the respondents had monthly income below
Rs. 7000 and 36% of the respondents had monthly income Rs. 7001 to 10,000 and 9% of
the respondents had monthly income Rs. 10,001 to 13,000, and finally 22% of the
respondents had monthly income Rs. Above 13,000. It is observed that majority of nurses
belong to middle class.
63
Table 6. Association between income per month and view of Nurses
N = 80
Negative Neutral Positive

Total
Income
View View View
χ2
(in Rs. Per
( 1 – 77) ( 78 – 154) (155 – 230)
month)
N % N % N % N %
- - - - 26 33.0 26 33.0
Below 7000
7001-10000 - - 1 100.0 28 35.0 29 36.0 34.62
Significant
10,001-13000 - - - - 7 9.0 7 9.0
.001 level
Above 13,000 - - - - 18 23.0 18 22.0
Total - - 1 100.0 79 99.0 80 100.0
accepted. It shows that there is a significant association between the income per month
and nurses view regarding management of environmental stress among High- risk
64
6. Distribution of respondents according to Professional qualification
Figure 8: Bar diagram depicting percentage distribution of respondents according to
Professional qualification
INTERPRETATION:
Bar diagram shows that 60 % of the respondents were GNM, 19 % of the
respondents were B.Sc. (N), 14% of the respondents were PB.B.Sc. (N), and finally 7%
of the respondents were M.Sc. (N). It was inferred that majority of nurses were educated
up to GNM.
65
Table 7. Association between Professional qualification and view of Nurses
N = 80

Professional
View View View
qualification χ2
( 1 – 77) ( 78 – 154) (155 – 230)
N % N % N % N %
GNM - - 1 100.0 47 59.0 48 60.0
B.Sc. (N) - - - - 15 19.0 15 19.0

81.99
PB.B.Sc(N) - - - - 11 14.0 11 14.0 significant
0.001
level
M.Sc. (N) - - - - 6 8.0 6 7.0
Total - - 1 100.0 79 100.0 80 100.0
accepted. It shows that there is a significant association between the professional
qualification and nurse’s view regarding management of environmental stress among
High- risk newborn admitted in Neonatal Intensive Care Unit (NICU).
66
7. Distribution of respondents according to total years of working experience as a
staff nurse
Figure 9: Pie diagram depicting percentage distribution of respondents according to total
years of working experience as a staff nurse.
INTERPRETATION:
Pie diagram shows that 21% of the respondents were having less than I year
working experience; 29% of the respondents were having 1 to 5 yrs of working
experience; 12% of the respondents were having 6 to 10 yrs of working experience; and
finally 38% of the respondents were having above 11 years of working experience. It was
inferred that majority of nurses were having above 11 years of working experience.
67
Table 8. Association between the total years of working experience as a staff nurse
and view of Nurses
N=80
Total years Negative Neutral Positive Total

of working View View View
( 1 – 77) ( 78 – 154) (155 – 230) χ2
experience
as a staff
nurse N % N % N % N %
Less than - - - - 17 22.0 17 21.0

1 year
- - 1 100.0 22 28.0 23 29.0 30.87

1 – 5 years
significant
6 – 10 years - - - - 10 12.0 10 12.0
0.001
Above - - - - 30 38.0 30 38.0 level

11 years
Total - - 1 100.0 79 100.0 80 100.0
accepted. It shows that there is a significant association between the total years of
working experience as a staff nurse and nurse’s view regarding management of
Unit (NICU).
68
8. Distribution of respondents according to total years of working experience in
NICU.
Figure 10: Cylindrical diagram depicting percentage distribution of respondents
according to total years of working experience in NICU.
INTERPRETATION:Cylindrical diagram shows that 41% of the respondents were
having less than I year working experience in NICU; 35% of the respondents were having
1 to 5 yrs of working experience in NICU; 18% of the respondents were having 6 to 10
yrs of working experience in NICU; and finally 6% of the respondents were having above
11 years of working experience in NICU. It was inferred that majority of nurses were
having less than 1 year of working experience in NICU.
69
Table 9. Association between the total years of working experience in NICU and
view of Nurses.
N = 80

Total years
View View View
of working χ2
( 1 – 77) ( 78 – 154) (155 – 230)
experience
in NICU
N % N % N % N %
Less than
- - - - 33 42.0 33 41.0
1 year
1 – 5 years - - 1 100.0 27 34.0 28 35.0 47.49

significant
0.001
6 – 10 years - - - - 14 18.0 14 18.0
level
Above
- - - - 5 6.0 5 6.0
11 years
Total - - 1 100.0 79 100.0 80 100.0
The calculated value is greater than the table value (CV>TV). Hence, research hypothesis
is accepted. It shows that there is a significant association between the total years of
working experience in NICU and nurses view regarding management of environmental
stress among High- risk newborn admitted in Neonatal Intensive Care Unit (NICU).
70
9. Distribution of respondents according to the previous exposure in handling High-
risk newborn in family
Figure 11: Bar diagram depicting percentage distribution of respondents according to the
previous exposure in handling High- risk newborn in family.
INTERPRETATION:
Bar diagram shows that 100 % of the respondents were not having previous
exposure in handling High- risk newborn in family. It was inferred that majority of nurses
were not having previous exposure in handling High- risk newborn in family.
71
Table 10. Association between the previous exposure in handling High- risk
newborn in family and view of Nurses
N = 80
The Negative Neutral Positive Total

previous View View View
exposure in χ2
( 1 – 77) ( 78 – 154) (155 – 230)
handling
High- risk
newborn in N % N % N % N %
family
Yes - - - - - - 0 -
76.00
Significant
No - - 1 100.0 79 100.0 80 - .001level
Total - - 1 100.0 79 100.0 80 -
accepted. It shows that there is a significant association between the previous exposure in
handling High- risk newborn in family and nurses view regarding management of
Unit (NICU).
72
Part III: Distribution of overall view of nurses regarding management of
environmental stress among High- risk newborn admitted in Neonatal Intensive
Care Unit (NICU)
N: 80
Negative View (1-77) Neutral View (78-154) Positive View(155-230)
N % N % N %
- - 1 1.0 79 99.0
Table 11: reveals the distribution of overall nurse’s view regarding management of
Unit (NICU)
From the above table shows that 99% of nurses have positive view; 1% of the
nurses have neutral view and none of the nurses have negative view regarding
It was inferred that majority of nurses in selected hospitals; overall there is a
positive view regarding the management of environmental stress among High- risk
73
10. Distribution of overall view of nurses regarding management of environmental
stress among High- risk newborn admitted in Neonatal Intensive Care Unit (NICU).
Figure 12: Bar diagram depicting the distribution of overall view of nurses regarding
Intensive Care Unit (NICU), in selected hospitals.
74
Aspect wise assessment of view of nurses regarding management of environmental
stress among High- risk newborn admitted in Neonatal Intensive Care Unit (NICU)
Table 12: Distribution of view of nurses according to their aspect wise related to
Neonatal Intensive Care Unit (NICU) and High- risk newborn
Assessment on aspect wise views of nurses regarding

management of environmental stress among High- risk
No Statements newborn admitted in Neonatal Intensive Care Unit (NICU)
Negative View Neutral View Positive View
N % N % N %
I Statements on Neonatal Intensive Care Unit (NICU) and High- risk
newborn
NICU can
also be called
1 - - 1 1.0 79 99.0
as a special
care nursery
All babies
should be
admitted in
2 - - 1 1.0 79 99.0
NICU within
the first 24
hrs after birth
Premature
birth is the
most common
reason for
3 - - 0 0.0 80 100.0
babies need
Neonatal
Intensive
Care
The risk for
environmental
stress is equal
4 - - 2 2.0 78 98.0
for High- risk
and normal
baby

positive view regarding Neonatal Intensive Care Unit (NICU) and High- risk newborn.
75
environmental stress
Assessment on aspect wise views of nurses regarding

management of environmental stress among High-risk
newborn admitted in Neonatal Intensive Care Unit (NICU)
No Statements
N % N % N %
I Statements on Environmental Stress
Environmental
stress is related
5 to the - - 0 0.0 80 100.0
unfavourable
setting of NICU
Environmental
stress is due to
6 overstimulation - - 1 1.0 79 99.0
to the High-risk
newborns
The response to
stress at NICU
is depending on
7 - - 1 1.0 79 99.0
their
developmental
age and weight
Reduction of
environmental
stress will
8 increase quality - - 2 2.0 78 98.0
care at NICU
for High-risk
babies
positive view regarding Environmental Stress.
76
causes for environmental stress in NICU
Assessment on aspect wise view of nurses regarding

newborn admitted in Neonatal Intensive Care Unit (NICU)
No. Statements
N % N % N %
I Statements on Causes for environmental stress in NICU
Loud noise
will induce
motor arousal
9 like increase - - 0 0.0 80 100.0
intracranial
pressure and
hypoxemia
Light level in
the NICU is
10 - - 1 1.0 79 99.0
from 150 – 240
ftc
Bright light at
11 NICU will not - - 1 1.0 79 99.0
affect the babies
Normal light
level in the
12 NICU cause - - 2 2.0 78 98.0
retinopathy
of prematurity
Constant bright
light causes
13 irregular - - 0 0.0 80 100.0
heart rate among
High-risk babies
Premature babies
less than 30
weeks of
14 gestational age - - 1 1.0 79 99.0
will be more
sensitive to
frequent touch
77
Gentle touch
has no positive
15 effect on - - 1 1.0 79 99.0
premature infant
High-risk new
born babies are
16 more sensitive to - - 2 2.0 78 98.0
overstimulation
High-risk
newborn is
highly sensitive
17 to the - - 0 0.0 80 100.0
psychological
variation of
caregivers
Extended
position for
a longer period
18 can lead to - - 1 1.0 79 99.0
delay in motor
development
Heel stick
procedures and
venipuncture - - 1 1.0 79 99.0
19
are the sources
of pain
Frequent painful
procedures at
20 NICU will delay - - 2 2.0 78 98.0
the brain
development
positive view regarding causes for environmental stress in NICU.
78
Signs

newborn admitted in Neonatal Intensive Care Unit
No. Statements (NICU)
N % N % N %
Signs
Overstimulation
causes changes in
21 skin colour, - - 1 1.0 79 99.0
startling and
tremoring
Stiffening the
baby’s body and
22 turning head away - - 1 1.0 79 99.0
are not the sign of
overstimulation
The baby will
become frantic and
move extremities
23 - - 0 0.00 80 100.0
widely for
environmental
stress
positive view regarding Signs.
79
management of noise, bright light, positioning, massage, pain; kangaroo mother
care, music therapy.

newborn admitted in Neonatal Intensive Care Unit
No. Statements (NICU)
N % N % N %
I Statements on management of noise, bright light, positioning, massage,

pain, kangaroo mother care, music therapy
NOISE
Standard sound
level at Neonatal
24 Intensive Care - - 1 1.0 79 99.0
should be below
50Db
Removing
telephones or
silencing the ringer
25 - - 1 1.0 79 99.0
in NICU will
reduce the noise
level
Alarming sound of
all monitors and
26 ventilator can be set - - 0 0.00 80 100.0
according to
convenience
Repair and replace
27 noisy equipment - - 1 1.0 79 99.0
Objects should not

28 placed on occupied - - 1 1.0 79 99.0
incubators
Incubator door
29 should be handled - - 0 0.00 80 100.0
gently
80
BRIGHT LIGHT
Light level should
range from 40 –
30 100 ftc during day - - 1 1.0 79 99.0
and 5 – 10 ftc at
night
Provide dim light to
31 - - 1 1.0 79 99.0
avoid stress
Shield the infants
32 eyes especially at - - 0 0.00 80 100.0
night time
Cover incubator
and monitor with
33 - - 1 1.0 79 99.0
blanket to avoid
exposure to light
POSITIONING
Prone position
promotes good
34 - - 0 0.00 80 100.0
oxygenation than
supine position
Positioning
promotes
35 - - 1 1.0 79 99.0
neuromuscular
development
Nesting using
blanket will provide
36 - - 1 1.0 79 99.0
boundaries and
reduce stress
MASSAGE
Oil massage can be
37 given to High-risk - - 1 1.0 79 99.0
newborn
Oil massage
reduces the levels
38 of the stress - - 1 1.0 79 99.0
decrease the
hormone cortisol
Oil massage can be
given by stroking
39 - - 0 0.00 80 100.0
head, shoulder,
arms and legs.
81
PAIN
The newborn baby
40 can perceive the - - 1 1.0 79 99.0
pain
Clustering of care
41 - - 1 1.0 79 99.0
will minimize pain
Non-nutritive
sucking is effective
42 - - 0 0.00 80 100.0
in reducing pain
and stress.
KANGAROO MOTHER CARE
Kangaroo mother
care reduces stress
43 - - 1 1.0 79 99.0
among mother and
baby
Kangaroo mother
care can be
44 provided only by - - 1 1.0 79 99.0
mother
MUSIC THERAPY
Soft soothing music
will maintain
45 - - 1 1.0 79 99.0
respiratory rate and
reduce stress
Recording mothers
voice and playing
46 - - 1 1.0 79 99.0
for newborn baby
will reduce stress
positive view regarding the management of noise, bright light, positioning, massage,
pain, kangaroo mother care, music therapy.
82
DATA ON THE VIEW OF NURSES REGARDING MANAGEMENT OF
ENVIRONMENTAL STRESS AMONG HIGH-RISKNEWBORN ADMITTED IN
NICU
Mean standard deviation and range regarding view of nurses regarding
management of environmental stress among High-risk newborn admitted in NICU.
N=80
VIEW OF NURSES ON VARIOUS MAX.

MEAN SD RANGE
ASPECTS SCORE
Neonatal intensive care unit & High-risk 20 16.03 2.70 16.00

newborn
Environmental stress 20 16.87 2.51 16.00
Causes for environmental stress in NICU 60 50.11 14.19 48.00
Signs & Management of Noise, Bright

Light, Positioning, Massage, Pain, 130 103.58 13.00 104.00
Kangaroo mother care, Music therapy
Table-17 reveals the view of nurses on various aspects of management of environmental
stress among High-risk newborn admitted in NICU. The obtained mean values of
‘Neonatal intensive care unit & High-risk newborn’ was M=16.03 (SD=2.70),
‘Environmental stress’ was M=16.87 (SD=2.51), ‘Causes for environmental stress in
NICU’ was M= 50.11 (SD=14.19), ‘Signs & Management of Noise, Bright Light,
Positioning, Massage, Pain, Kangaroo mother care, Music therapy’ was M=103.58
(SD=13.00).
83
It was inferred that, the view of nurses were very positive towards signs &
management of Noise, Bright Light, Positioning, Massage, Pain, Kangaroo mother care,
Music therapy and followed by causes for environmental stress in NICU. However the
view of nurses towards environmental stress and Neonatal intensive care unit & High-risk
newborn were neutral.
84
W|ávâáá|ÉÇ
85
6. DISCUSSION
All men by nature desire knowledge-
-Henry Jacobson
The present study was conducted to assess the view of nurses regarding
Intensive Care Unit (NICU) in selected hospitals, Bangalore with a view to develop an
information booklet”.
In order to achieve the objectives of the study, descriptive survey approach with
descriptive design was adopted. The sample comprised of 80 nurses. The data were
collected from them by using a structured interview schedule.
The findings of the study are discussed under the following sections:
Socio-demographic characteristics of the sample
Findings revealed that the highest 54% of the nurses were in the age group of 21-30
years, 82% were females, 62% were unmarried, 60% of them were GNM, 41% were not
having children, 36% were belongs to middle class, 38% were having more than 11 years
of working experience as a staff nurse, 41% were having less than 1 year of working
experience in NICU and finally 100% were not having previous exposure in handling
High- risk newborn in family.
86
Assessment of view of nurses regarding management of environmental stress among
High- risk newborn admitted in Neonatal Intensive Care Unit (NICU).
Findings revealed that majority of nurses in selected hospitals; overall the view of
nurses were positive towards signs & management of Noise, Bright Light, Positioning,
Massage, Pain, Kangaroo mother care, Music therapy and followed by causes for
environmental stress in NICU. However the view of nurses towards environmental stress
and Neonatal intensive care unit & High- risk newborn were neutral.
Objective 1: To assess the view of nurses regarding management of environmental stress
among High- risk newborn admitted in Neonatal Intensive Care Unit (NICU)
Unit (NICU).
It was inferred that majority of nurses ; overall there is a positive view regarding
Objective 2: To find out the association between the views of nurses regarding
Intensive Care Unit (NICU) and selected socio-demographic variables.
nurses regarding management of environmental stress among High- risk newborn
87
admitted in Neonatal Intensive Care Unit (NICU) and selected socio demographic factors
such as Age χ2= 62.87(s); Gender χ2= 89.93(s); Marital status χ2= 43.92(s); Professional
qualification χ2=81.99(s); Number of children χ2=49.62(s); Income per month χ2 =
34.62(s); Total years of working experience as a staff nurse χ2 = 30.87(s); Total years of
working experience in NICU χ2 = 47.49(s); and finally previous exposure in handling
High- risk newborn in family χ2 = 76.00 (s) at 0.001 level.
Therefore, it was inferred that the socio-demographic factors such as age, gender,
marital status, professional qualification number of children, income per month, total
years of working experience as a staff nurse, total years of working experience in NICU,
previous exposure in handling High- risk newborn in family, shows there is a significant
association between the view of nurses and socio-demographic variables (P>0.001 level).
88
VÉÇvÄâá|ÉÇ
89
7. CONCLUSION
“Not to know is bad, not to wish to know is worse”
-Steve Droke
The aim of the study “to assess the view of nurses regarding management of
Unit (NICU) in selected hospitals, Bangalore with a view to develop an information
booklet”.
The following conclusions were drawn from the result of the study.
Findings revealed that the highest 54% of the nurses were in the age group of
21-30 years, 82% were females, 62% were unmarried, 60% of them were GNM, 41%
were not having children, 36% were belongs to middle class, 38% were having more than
11 years of working experience as a staff nurse, 41% were having less than 1 year of
working experience in NICU and finally 100% were not having previous exposure in
handling High- risk newborn in family.
It was inferred that the socio-demographic factors such as age, gender, marital status,
professional qualification number of children, income per month, total years of working
experience as a staff nurse, total years of working experience in NICU, previous exposure
in handling high- risk newborn in family, shows there is a significant association between
the view of nurses and socio-demographic variables (P > 0.001 level).
Findings revealed that majority of nurses in selected hospitals; overall view of
nurses were very positive towards signs & management of noise, bright light, positioning,
90
massage, pain, kangaroo mother care, music therapy and followed by causes for
environmental stress in NICU. However the view of nurses towards environmental stress
and Neonatal intensive care unit & High- risk newborn were neutral.
It was inferred that majority of nurses, overall there is a positive view regarding
Implications of the study
The findings of the study has implications in nursing education, nursing practice,
nursing administration and nursing research.
Nursing Education
Nursing profession present and future require qualified nurses to meet the
challenges and deliver health care in all setting. The student nurses are the growing buds
of our nursing profession. The nursing curriculum should include the contemporary
approach for care of High-risk newborns in NICU. It should also emphasis on proper
assessment of stress responses to environmental stimuli.
Nursing practice
Nursing personnel need to be aware of environmental stress among High- risk
newborn admitted in NICU. Protocol can be used to learn how to manage the
environmental stress in NICU. Nurses also need to give more attention to integrate the
neuro developmental care in NICU. They can also able to diagnose stress related
91
problem and help the newborn to attain developmental outcome. Nurses should improve
awareness to manage the environmental stress among High- risk newborn in NICU.
Nursing Administration
Assessing and managing the environmental stress is an essential component to
promote the holistic and quality nursing care to NICU babies. The functions of
administrator is not only plays their role in hospital setting but also they are the right
person to introduce assessment of environmental stress among High- risk newborns in
NICU. A small training course about developmental care in NICU will provide
guidelines for the health care workers. The hospital policy can implement the guidelines
for the nurses working in Neonatal intensive care unit. Nurse administrators should
encourage the use of environmental stress reduction techniques in Neonatal intensive care
unit.
Nursing Research
Nurse researchers can encourage clinical nurses to apply the research findings in
their daily nursing care activities to reduce environmental stress among High- risk
newborn admitted in NICU. They can promote more research with regard to utilization of
various techniques to reduce environmental stress in clinical practice. This will increase
thirst for the evidence based practice and effective research approaches in health
promotion.
92
Suggestions
1. Hospital policies can formulate the protocol to assess environmental stress and
management techniques among High- risk newborn in NICU.
2. Nurse educators should give training for nurses regarding the use of various stress
reduction techniques.
3. In-service education/continuing education can be conducted for nurses as well as
student nurses to increases their knowledge regarding management of
environmental stress among High- risk new born in NICU, which in turn reduce
incidence of stress among High- risk new born.
4. The conference can be conducted on the same topic for all the health care
professionals like Junior Doctors, Nurses, because they are involved in Neonatal
Care.
Recommendations:
The following recommendations are drawn
1. The study can be replicated on a large sample.
2. A study can be conducted to assess the knowledge and practice of nurses on
various techniques to reduce environmental stress among High- risk babies in
NICU.
3. A study can be conducted to assess the effectiveness of various relaxation
techniques to reduce environmental stress among High- risk babies in NICU.
4. The study can be replicated as a longitudinal study with follow up.
5. The same study can conducted with qualitative approach.
93
6. This same study can be conducted in structured teaching module.
7. An experimental study can be conducted to find out the causes for environmental
stress among High-risk newborn in NICU.
Limitations of the study
The limitations of the present study include:
1. The finding of the study could not be generalized in view of small sample size
and limited area of setting.
2. The study also limits with available data collection period.
3. Data collection was limited with tool which is prepared by the investigator.
4. The findings of the study were limited to 80 staff nurses from selected hospitals,
Bangalore.
94
fâÅÅtÜç
95
8. SUMMARY
“Knowledge transfers confidence, And confidence makes the practice effective”
Jon Brado
Statement of the problem
‘’ A study to assess the view of nurses regarding management of environmental
stress among High- risk newborn admitted in Neonatal Intensive Care Unit (NICU) in
selected hospitals, Bangalore with a view to develop an information booklet’’.
among High- risk newborn admitted in NICU.
2. To find out the association between view of nurses regarding management of
Methodology
The primary aim of the study was “ to assess the view of nurses regarding
Intensive Care Unit (NICU) in selected hospitals, Bangalore with a view to develop an
information booklet’’.
The study was conducted at Indira Gandhi Institute of child health, Vyedehi
Institute and Research center, Gunasheela, Dr. Malathi Manipal Hospital. A formal
written permission was obtained from the higher authorities. The present study was
descriptive in nature, conducted over a period of 6 weeks from 1st November 2012 to 30th
96
January 2012. The conceptual framework used for the study was based on modified
king’s Goal attainment theory. Purposive sampling technique was used to select 80
samples of staff nurses from the selected hospitals at Bangalore.
The instrument used for the data collection was structured questionnaire. Tool
consisted of three sections:
Section A- Socio - Demographic variables.
Section B- Structured questionnaire.
The prepared tool was validated by subject experts and the reliability of tool was
tested. The reliability of the tool was computed by using Karl Pearson split half method.
The tool was found to be reliable. The Pilot study was conducted from 1/10/2012 by
selecting 8 staff nurses who were working in NICU in Ramakrishna hospital, Bangalore.
The data obtained were analyzed and interpreted in terms of the objective of the study.
Descriptive and inferential statistics were used for data analysis.
Examining the Hypothesis
Formulated Hypothesis:
H1: There will be a significant association between the view of nurses regarding
management of environmental stress with selected demographic variables.
nurses regarding management of environmental stress among High-risk newborn
admitted in Neonatal Intensive Care Unit (NICU) and selected socio demographic
factors such as Age χ2= 62.87(s); Gender χ2= 89.93(s); Marital status χ2= 43.92(s);
Professional qualification χ2=81.99(s); Number of children χ2=49.62(s); Income per
97
month χ2 = 34.62(s); Total years of working experience as a staff nurse χ2 = 30.87(s);
Total years of working experience in NICU χ2 = 47.49(s); and finally previous exposure
in handling High- risk newborn in family χ2 = 76.00 (s) at 0.001 level.
Therefore, it was inferred that the socio-demographic factors such as age, gender,
marital status, professional qualification number of children, income per month, total
years of working experience as a staff nurse, total years of working experience in
NICU, previous exposure in handling High- risk newborn in family, shows there
(P > 0.001 level).
The findings are summarized as follows.
The findings of the study are discussed under the following sections:
Socio-demographic characteristics of the sample:
Findings revealed that the highest 54% of the nurses were in the age group of 21-30
years, 82% were females, 62% were unmarried, 60% of them were GNM, 41% were not
having children, 36% were belongs to middle class, 38% were having more than 11 years
of working experience as a staff nurse, 41% were having less than 1 year of working
experience in NICU and finally 100% were not having previous exposure in handling
High- risk newborn in family.
Assessment of aspect wise view of nurses regarding management of environmental

stress among High- risk newborn admitted in Neonatal Intensive Care Unit (NICU):
Findings revealed that majority of nurses in selected hospitals; overall aspect wise
the view of nurses were very positive towards signs & management of noise, bright light,
positioning, massage, pain, kangaroo mother care, music therapy and followed by causes
98
for environmental stress in NICU. However the view of nurses towards environmental
stress and Neonatal intensive care unit & High- risk newborn were very neutral.
Objective 1: To assess the view of nurses regarding management of environmental stress
among High- risk newborn admitted in Neonatal Intensive Care Unit (NICU)
environmental stress among High-risk newborn admitted in Neonatal Intensive Care Unit
(NICU).
It was inferred that majority of nurses ; overall there is a positive view regarding
Intensive Care Unit (NICU)
Objective 2: To find out the association between the views of nurses regarding
Intensive Care Unit (NICU) and selected socio-demographic variables
nurses regarding management of environmental stress among High- risk newborn
admitted in Neonatal Intensive Care Unit (NICU) and selected socio demographic factors
such as Age χ2= 62.87(s); Gender χ2= 89.93(s); Marital status χ2= 43.92(s);
Professional qualification χ2=81.99(s); Number of children χ2=49.62(s); Income per
month χ2 = 34.62(s); Total years of working experience as a staff nurse χ2 = 30.87(s);
Total years of working experience in NICU χ2 = 47.49(s); and finally previous exposure
in handling High- risk newborn in family χ2 = 76.00 (s) at 0.001 level.
99
Therefore, it was inferred that the socio-demographic factors such as Age,
Gender, Marital status, Professional qualification Number of children, Income per month,
Total years of working experience as a staff nurse, Total years of working experience in
NICU, Previous exposure in handling High- risk newborn in family, shows there
(P > 0.001 level).
100
U|uÄ|ÉzÜtÑ{ç
101
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108
TÇÇxåâÜx
TÇÇxåâÜxá
109
1. ANNEXURE
ANNEXURE – I
110
111
112
113
114
ANNEXURE –II
LETTER REQUESTING THE OPINION OF EXPERT’S ON CONTENT
VALIDITY OF THE TOOL AND INFORMATION BOOKLET.
From,
Ms. Jilu James
2nd year MSc (N) student
To,
.................................................
Forwarded through
Principal
Respected sir/Madam
Sub: Requisition for expert opinion and suggestion for content validity of the tool.
I Ms. Jilu James a student of MSc Nursing 2nd year in T. John College of
Nursing affiliated to Rajiv Gandhi University of health sciences Bangalore. As a
partial fulfilment of MSc Nursing program, I am conducting a study on “ A
STUDY TO ASSESS THE VIEW OF NURSES REGARDING
MANAGEMENT OF ENVIRONMENTAL STRESS AMONG HIGH- RISK
115
NEWBORN ADMITTED IN NEONATAL INTENSIVE CARE UNIT, IN
SELECTED HOSPITALS BANGALORE,WITH A VIEW TO DEVELOP AN
INFORMATION BOOKLET.”Tool for my project has to be validated by experts.
I request you to kindly go through the content of tool and information Booklet,
and give your valuable opinion on the same. I also request you to kindly sign the
certificate stating that you have validated the tool. Please suggest modifications
where ever possible.
Thanking you in anticipation
Here I am enclosing the copy of
Information booklet
Structured interview schedule
d) Criteria checklist
e) Validity certificate
Thanking You,
Place: Yours faithfully
Date: ( Jilu James)
116
ANNEXURE –III
ACCEPTANCE FORM FOR TOOL VALIDATION
Name:
Designation:
Name of the college/hospital:
Statement of acceptance or non acceptance
I give my acceptance/non-acceptance to validate tool and Information booklet.
Topic: “A study to assess the view of nurses regarding management of environmental
stress among High- risk newborn admitted in neonatal intensive care unit, in selected
hospitals at, Bangalore, with a view to develop an information booklet” .
Place: Signature:
Date:
117
ANNEXURE –IV
CONTENT VALIDATION CERTIFICATE
I hereby certify that I have validated the tool and Information booklet of Jilu
James, IInd year MSc Nursing Student, T. John College of Nursing who is undertaking
the following study:
“A study to assess the view of nurses regarding management of environmental
stress among High- risk newborn admitted in neonatal intensive care unit, in selected
hospitals at bangalore, with a view to develop an information booklet.”
Place: Signature of the expert:
Date:
Designation and address:
118
ANNEXURE –V
EVALUATION CRITERIA CHECKLIST

Dear sir/Madam,
Kindly go through the content and place right mark against questions in the
following columns ranging from relevant to not relevant, whether need modification,
kindly give your opinion in the remark column.
SECTION I
DEMOGRAPHIC DATA
SL:NO: ITEMS RELEVANT NEED NOT REMARK

MODIFICATION RELEVANT
1
2
3
4
5
6
7
8
9
Signature of the Evaluator:
Suggestions: Name and Designation:
………………………………………………………………………………………….......
………………………………………………………………………………………….......
119
EVALUATION CRITERIA CHECK LIST (Information booklet)
Respected Sir/Madam,
Kindly go through the content and rate the content in the appropriate column and
your expert opinion and suggestion in the remark column if found not relevant or needs
modification.
Sl Need Not
Content Relevant Remarks
No Modification Relevant
Objectives
• Respond oriented
1 • Realistic to
achieve
Selection of content
• Adequate content
Objectives
• According to the
participant
2
cognitive level
• Aims at high
level of wellness
• Continuing of the
content observed
Organisation of content
• Arrange in logical
sequence
3 • Integration of the
content from
simple to
complex
Language
• Simple
comprehend
4 • Clear to perceive
the
• Meaning of the
content
120
Visual image used
• Relevant to the
content
• Represents
5 adequate to the
concept of
content
• Clear and
understandable
Fesibility and
practicability of
information booklet
• Permits self
6
learning
• Interesting and
useful to Staff
Nurses
Comments:………………………………………………………
……………………………………………………………………
……………………………………………………………………
………………………………………………………………….....
………………………………………………………………………
……………………………………….
Date: Name
Place Signature of Expert
121
ANNEXURE –VII
CONSENT FORM (ENGLISH)
I am MSc Nursing student of T. John College of nursing. I have selected a study,
“ A study to assess the view of nurses regarding management of environmental
stress among High- risk newborn admitted in neonatal intensive care unit ( NICU)
in selected hospitals at Bangalore with a view to develop an Information booklet’’. I
request you to participate in my study. You will be required to answer the questions
honestly. The information finished by you will be kept confidential and will be used only
for the study purpose.
Place:
Signature of the participant
Date:
122
ANNEXURE –VII
TOOL USED FOR THE STUDY (ENGLISH)
The tool contains three Sections:-
Section A: Demographic and Clinical variables.
Section B: Structured interview schedule
Dear Participant,
I kindly request you to answer the tool and indicate your response carefully.
Code No:
Date :
SECTION – A
Put tick mark () against most appropriate choice.
SOCIO-DEMOGRAPHIC VARIABLES
1. Age
a) 21-30 years ( )
b) 31-40 years ( )
c) 41-50 years ( )
d) 51-60years ( )
123
2. Gender
a) Male ( )
b) Female ( )
3. Marital status
a) Unmarried ( )
b) Married ( )
c) Widow/Widowers ( )
d) Separated/ Divorce ( )
4. Number of Children
a) One ( )
b) Two ( )
c) Above Two ( )
d) None ( )
5. Income/Month
a) Rs. Less than 7000 ( )
b) Rs. 7001-Rs.10000 ( )
c) Rs. 10001- Rs. 13000 ( )
d) Above Rs.13000 ( )
6. Professional qualification.
a) General Nursing and Midwifery ( )
b) Bachelor of Science in Nursing ( )
c) Post Basic Nursing ( )
d) Master of science in Nursing ( )
124
7. Total years of working experience as a Staff Nurse.
a) Less than 1 years ( )
b) 1-5 years ( )
c) 6-10 years ( )
d) Above 11 years ( )
8. Total years of working experience in Neonatal Intensive Care Unit.
a) Less than 1 years ( )
b) 1- 5 years ( )
c) 6- 10 years ( )
d) Above 11years ( )
9. Do you have any previous exposure in handling High- risk newborn in your family?
a) Yes ( )
b) No ( )
125
SECTION B
INSTRUCTION: Five responses are given for each statement. The respondent is
required to place a () against your opinion. Please select only one response and
answer to all statement given below.
Strongly support
Support
Neither support nor oppose
Oppose
Strongly oppose
Neither
Sl Strongly Support Strongly
Support Oppose
No Items Support Nor Oppose
Oppose
NEONATAL INTENSIVE
CARE UNIT AND HIGH-
RISK NEWBORN
Neonatal Intensive Care Unit
1 can also be called as a special
care nursery.
All babies should be admitted
2 in NICU within the first 24 hrs
after birth.
Premature birth is the most
common reason for babies
3
requiring Neonatal Intensive
Care.
The risk for environmental
4 stress is equal for High- risk
and normal baby.
ENVIRONMENTAL
STRESS
Environmental stress is related
to immaturity of newborn and
5
the unfavourable setting of
NICU
Environmental stress is due to
6 overstimulation to the High-
risk newborns.
126
The response to stressors at
7
NICU is depending on their
developmental age and weight.
Reduction of environmental
8 stress will increase quality care
at NICU for High- risk babies.
CAUSES FOR
ENVIRONMENTAL
STRESS IN NICU
Loud noise will induce motor
arousal like increase
9
intracranial pressure and
hypoxemia.
Light level in the NICU is
10
ranged from 150-240 ftc.
Bright light at NICU will not
11
affect the babies
Normal light level in the
12 NICU may be cause
retinopathy of prematurity.
Constant bright light causes
13 irregular heart rate among
High- risk babies.
Premature babies less than 30
weeks of gestational age will be
14
more sensitive to frequent
touch
Non- procedural/ gentle touch
15 has no positive effect on
premature infant.
High- risk newborn babies are
16 more sensitive to
overstimulation.
High- risk newborn is highly
17 sensitive to the psychological
variation of caregivers.
Extended position for a longer
18
period can lead to delay in
motor development
Heel stick procedures and
19 venipuncture are the sources of
pain.
127
Frequent painful procedures at
20 NICU will delay the brain
development.
SIGNS
Overstimulation causes
21 Changes in skin colour,
startling, and tremoring.
Stiffening the baby’s body and
22 turning head away are not the
sign of overstimulation.
The baby will become frantic
23 and move extremities widely
for environmental stress.
MANAGEMENT
NOISE
Standard sound level at
24 Neonatal Intensive Care should
be below 50dB .
Removing telephones or
25 silencing the ringer in NICU
will reduce the noise level.
Alarm sound of all monitors
26 and ventilator can be set
according to convenience.
Repair and replace noisy
27
equipment
Objects should not placed on
28
occupied incubators.
Incubator door should be
29
handled gently.
BRIGHT LIGHT
Light level should range from
30 40-100 ftc during day and 5-10
ftc at night.
Provide dim light to avoid
31
stress
Shield the infant’s eyes
32
especially at night time.
Cover Incubator and monitor
33
with blanket to avoid exposure
to light.
128
POSITIONING
34 Prone position promotes good
oxygenation than supine
position
35 Positioning promotes
neuromuscular development
36 Nesting using blanket will
provide boundaries and reduce
stress.
MASSAGE
37 Oil massage can be given to
High- risk newborn.
38 Oil massage reduces the levels
of the stress decrease the
hormone cortisol.
39 Oil massage can be given by
stroking head, shoulder, arms
and legs.
PAIN
40 The newborn baby can perceive
the pain.
41 Clustering of care will
minimize pain.
42 Non-nutritive sucking is
effective in reducing pain and
stress.
KANGAROO MOTHER
CARE
43 Kangaroo mother care reduces
stress among mother and baby.
44 Kangaroo mother care can be
provided only by mother
MUSIC THERAPY
45 Soft soothing music will
maintain respiratory rate and
reduce stress
46 Recording mothers voice and
playing for newborn baby will
reduce stress.
129
ANNEXURE –IX
LIST OF VALIDATORS
1. Mrs. Babhani, MSc (N) Prof and HOD

Paediatric NursingDepartment
The Oxford College of Nursing
Bangalore 68.
2. Mrs. Anu Mathew, Asst. Professor

Syamala Reddy College of Nursing
Bangalore.
3. Mrs. Menagha Gandhi ,Asst. Professor

Paediatric Nursing Department
Chinai College of Nursing
Bangalore
4. Mrs. Dhanalakshmi, Asst. Professor

Rajiv Gandhi College of Nursing
Bangalore.
5. Mrs. Priya, Asso Professor

Spurthy College of Nursing
Bangalore.
6. Dr. C.Niranjan
Neonatologist
Indiragandhi Institute of child health Hospital,
Bangalore.
7. Dr. R.Ramalakshman
Neonatologist
Sagar Apollo Hospital,
Bangalore.
8. Dr. Mrs. Ruby John

Professor in Biostatics
Bangalore- 72.
130
ANNEXURE –X
LIST OF FORMULAE USED
1. Karl Pearson’s Correlation Coefficient
2. Spearman’s Brown Prophecy formula
2r
r1 = _____________
1+ r
r = Correlation coefficient computed on split halves.
r1= The estimated reliability of the entire test.
3. Chi-square formula
N(ad - bc)2
2
X = ___________________
(a+b) (c+d) (a+c) (b+d)
4. Standard Deviation
∑ (di - d)2
Sd= ___________
n-1
_
∑(di- d)2 = ∑ di2 - (∑di)2
-----------
n
131

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“A STUDY TO ASSESS THE VIEW OF NURSES REGARDING MANAGEMENT

OF ENVIRONMENTAL STRESS AMONG HIGH-RISK NEWBORN ADMITTED

Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled “A STUDY TO ASSESS THE

VIEW OF NURSES REGARDING MANAGEMENT OF ENVIRONMENTAL

STRESS AMONG HIGHRISK NEWBORN ADMITTED IN NEONATAL

INTENSIVE CARE UNIT (NICU) IN SELECTED HOSPITALS,

BANGALORE WITH A VIEW TO DEVELOP AN INFORMATION BOOKLET.”

Asst. Prof. Mrs. R. Ramalakshmi, (HOD), Dept of Paediatric Nursing, T. John

College of Nursing, Gottigere, Bangalore.

Date: Signature of the Candidate

Place: Bangalore Ms. Jilu James

This is to certify that the dissertation entitled “A STUDY TO ASSESS THE

VIEW OF NURSES REGARDING MANAGEMENT OF ENVIRONMENTAL

STRESS AMONG HIGHRISK NEWBORN ADMITTED IN NEONATAL

INTENSIVE CARE UNIT (NICU) IN SELECTED HOSPITALS, BANGALORE

WITH A VIEW TO DEVELOP AN INFORMATION BOOKLET” is a bonafide

degree of Master of Science in Nursing in Paediatric Nursing.

Date: Signature of the Guide

Place: Bangalore Mrs. R. Ramalakshmi

Asst. Professor, (HOD)

Department of Paediatric Nursing

T. John College of nursing

This is to certify that the dissertation entitled “A STUDY TO ASSESS THE

VIEW OF NURSES REGARDING MANAGEMENT OF ENVIRONMENTAL

STRESS AMONG HIGHRISK NEWBORN ADMITTED IN NEONATAL

INTENSIVE CARE UNIT (NICU) IN SELECTED HOSPITALS, BANGALORE

WITH A VIEW TO DEVELOP AN INFORMATION BOOKLET” is a bonafide

Ramalaksmi, (HOD), Dept. of Paediatric Nursing, T. John College of Nursing,

Mrs. R. Ramalakshmi Prof. Mrs. P. Neelavathi

Date: Place: Bangalore.

Declaration by the candidate

I hereby declare that the Rajiv Gandhi University of Health sciences,

in print or electronic format for academic/research purpose.

Date: Signature of the candidate,

Place: Bangalore. Ms. Jilu James.

© Rajiv Gandhi University of Health Sciences, Karnataka

“This is the lord’s doing; it is marvellous in our eyes.”

I am extremely thankful to Dr. Thomas. P. John, Chairman, T. John Group of

I would like to express my heartfelt gratitude and regard to my guide

I would like to express my heartfelt gratitude and regard to

I am profoundly indebted to Mrs. Gladish George, HOD, Dept. of Medical

Heartfelt thanks to Mrs. Uma Maheswari, Lecturer, Dept. of Paediatric nursing,

I express my sincere thanks to Mrs. Tintu C. Francis, Lecturer, T. John college

I express my sincere thanks to Mr. Venkatesh.M.P, HOD, Vinayaka mission

I extend my hearty thanks to Management & Head of Institution of Indira

I am very much grateful to my beloved Parents James Mathew and Lovely

It gives me great pleasure to express my heartfelt gratitude to my husband

I would like to thank S K Enterprises, J P Nagar for their prompt service.

Date: Signature of the Candidate

Place: Jilu James.

NICU Neonatal intensive care unit

i.e That is.

SPL Sound pressure level

KMC Kangaroo mother care

LBW Low birth weight

SPL Sound pressure level

WHO World Health Organisation

A study entitled “A study to assess the view of nurses regarding management of

(NICU) in selected hospitals, Bangalore with a view to develop an information booklet”

Background of the study

in NICU, as a worldwide. High-risk newborns are exposed to various forms of