Being with Babies: Vocal soothing for preterm infants during painful procedures in the Neonatal Intensive Care Unit

Abstract

Traditionally infant mental health needs have been attended to in the Neonatal Intensive Care Unit (NICU) by supporting parent-infant relationships. There has been little focus in either the Nursing or the Infant Mental Health literature on the role that non-parental caregivers have in supporting preterm infant social and emotional development. Infants in the NICU experience many painful and stressful procedures yet there is evidence that both pharmacological and non-pharmacological methods of pain relief are under-used in the preterm infant population. This PhD programme of research investigated the NICU nurse-infant relationship, with a focus on vocal soothing. Two observational studies investigated the use of voice by NICU nurses during painful and non-painful procedures. A model of vocal soothing was developed and tested for its ability to provide comfort to preterm infants undergoing painful procedures.

Two observational studies recorded the numbers of words spoken to 50 infants in NICU during two procedures; a painful one (heel prick) and a non-painful one (nappy change). Three feasibility studies tested the proposed methods and refined the planning for a study that assessed the effectiveness of the vocal soothing intervention in reducing manifestations of pain and stress in preterm infants during painful procedures. In the first feasibility study the research protocol was tested with twenty infants and their nurses. The remaining two feasibility studies further refined the methods for collecting enough saliva from preterm infants for salivary cortisol analysis. In the main study for this PhD research programme, fifty-one infants received both the intervention condition (vocal soothing) and the control condition (silence) during two routine heel prick blood tests in their first 10 days of life. Measures of stress included cortisol, heart rate and oxygen saturation. Pain was measured using the Premature Infant Pain Profile Revised (PIPP-R). Nurses were found to speak infrequently to infants during both painful and non-painful procedures, but were less likely to speak to infants during painful procedures than during non-painful procedures. The feasibility studies led to changes in methods that included the researcher providing the intervention rather than the nurses, the use of a polygraphic system for recording the physiological data and the administration of a 5% aqueous solution of citric acid to increase saliva volume. The results of the main study found no statistically significant differences in cortisol response or physiological data between the vocal soothing and control conditions, although there was some indication that the vocal soothing intervention is unlikely to have an adverse effect on preterm infant cortisol levels. In bringing together the results of these studies, this thesis argues that vocal soothing is an important aspect of emotional care in the NICU. A case is made for ‘companionship’ as a concept that promotes attuned emotionally sensitive care by non-parental caregivers. The international problem of the under-use of pain management interventions is viewed through a psychoanalytic lens and it is proposed that the psychological defence of denial may be a contributing factor. Future directions for research are suggested, including the emotional experience of NICU nurses and the efficacy of a ‘psyche-education’ for improving pain management practices in the NICU.