Journal of Neonatal Nursing (2016) 22, 108e114 www.elsevier.com/jneo ORIGINAL ARTICLE Nurses’ experiences using conventional overhead phototherapy versus fibreoptic blankets for the treatment of neonatal hyperbilirubinemia Anne Marit Føreland, Master in, Pediatric Nursinga,*, Lene Rosenberg, Master in, Intensive Care Nursinga, Berit Johannessen, Ph.D, Associate Professorb a Sørlandet Hospital (SSHF), Postbox 416, 4604 Kristiansand S, Norway Institute of Health and Nursing Science, University of Agder, Postbox 422, 4604 Kristiansand S, Norway b Available online 21 January 2016 KEYWORDS Phototherapy; Fibre optic; Bilirubin; Family-centred care; Bonding; Satisfied; Harm; NICU Abstract Background: In some neonatal intensive care units (NICUs), conventional overhead phototherapy is the only phototherapy available, whereas others use fibreoptic blankets only. Several NICUs use both treatments interchangeably. Aim: To explore how nurses experience the use of conventional versus fibreoptic phototherapy. Method: Six qualitative in-depth interviews involving nurses at three different NICUs with experience in both treatments were conducted. Results: Following experiences were revealed: i) Infants displayed discomfort while under phototherapy, whereas blanket use promoted infant satisfaction. ii) Blankets increased parents’ satisfaction by facilitating bonding, breastfeeding and kangaroo care. iii) The nurses disagreed as to whether fibreoptic blankets and conventional treatment have similar effects. iv) Nurses were concerned about the possible harm and discomfort to the eyes and skin of infants caused by phototherapy. * Corresponding author. Tel.: þ47 98470410. E-mail address: [email protected] (A.M. Føreland). http://dx.doi.org/10.1016/j.jnn.2016.01.001 1355-1841/ª 2016 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. Nurses’ experiences using conventional versus fibreoptic phototherapy 109 Conclusion: When the efficacy was considered sufficient, nurses preferred blankets compared with conventional overhead, because of ability to facilitate infant comfort and parentechild interaction. ª 2016 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. Introduction Aim Phototherapy is the use of visible light for the treatment of neonatal hyperbilirubinemia or jaundice. It is a major strategy for the prevention of bilirubin-induced brain damage and is considered a relatively harmless intervention (Wong et al., 2006). Many different devices are available, but there is no international standardized practice. In conventional phototherapy, the infant is placed in a bed or incubator with a light-source placed 10e50 cm overhead. A new method that delivers light from a high-intensity lamp to a fibreoptic panel came into use around 1990 (Murphy and Oellrich, 1990). These devices take the form of beds, pads and blankets of different sizes and designs. Various studies have examined the efficacy of conventional versus fibreoptic devices, but the results vary widely because of differences in the light source and configuration (Bhutani, 2011; van Imhoff et al., 2013). Some studies have focused on phototherapy and maternal experiences but have not compared conventional versus fibreoptic phototherapy. Phototherapy is frequently a difficult and emotionally stressful time for mothers (Brethauer and Carey, 2010; Hannon et al., 2001), and it can interfere with breastfeeding (Willis et al., 2002). Modern neonatal intensive care units (NICUs) emphasize the importance of the family, and ‘family-centred care’ (FCC) is considered the best approach for providing paediatric care (Shields et al., 2012). Szucs and Rosenman’s (2013) case report focused on the challenge of providing effective phototherapy within the framework of FCC. A Cochrane review found that research into the possible advantages of fibreoptic over conventional phototherapy was required (Mills and Tudehope, 2001). In some NICUs, conventional overhead is still the only phototherapy treatment available, whereas others use fibreoptic blankets only. Several NICUs use both treatments interchangeably. There is a lack of studies concerning nurses’ experiences using conventional versus fibreoptic phototherapy in the NICU. The aim of this study was to explore how nurses experience the use of conventional versus fibreoptic phototherapy in neonatal care. Method A qualitative research design using individual semistructured interviews was chosen (Malterud, 2012). The study was conducted in three Norwegian NICUs in October 2013: one regional and university hospital, and two district general hospitals. Two of the selected hospitals used both conventional and fibreoptic phototherapy. One hospital had stopped using conventional devices and used fibreoptic blankets only. Two nurses in each hospital were interviewed. The inclusion criteria were: (i) a minimum of two years’ experience with phototherapy and (ii) experience with both conventional overhead and fibreoptic blanket phototherapy. Each interview lasted about 45 min. The interviews followed a semi-structured interview guide with four main themes: experiences using conventional phototherapy, experiences using fibreoptic blankets, perceived advantages and disadvantages, and perceived differences between the methods. The interviews were transcribed verbatim into 92 pages of transcript, and analysed by systematic text condensation (STC) as developed by Malterud (2011). STC is inspired by Giorgi’s phenomenological method and includes four steps. 1) Obtain an overview of the data and identify preliminary themes. 2) Identify and code the meaning units relevant to the study question. 3) Condense and sort the content in each code group into subgroups. 4) Reconceptualise the data by synthesizing the content of the condensates and develop descriptions. This process resulted in nine pages of text, which were divided into four main categories. Ethical considerations The study protocol was approved by the Faculty Research Ethics Committee, the Norwegian Social Science Data Service and the hospitals’ research 110 A.M. Føreland et al. Table 1 Characteristics of the sample. Participant nurse and unit NICU experience (years) A, NICU 1 13 Auxiliary/ postgraduate education in neonatal or intensive nursing Yes B, NICU 1 17 Yes C, NICU 2 3 No D, NICU 2 14 No E, NICU 3 F, NICU 3 22 22 Yes Yes a Choice of light source Experience with conventional phototherapy (years) Experience with fibreoptic blanket phototherapy (years) Conventional and/ or fibreoptic Conventional and/ or fibreoptic Conventional and/ or fibreoptic 13 3 17 3 3 Conventional; fibreoptic when multiple therapy useda Fibreoptic Fibreoptic 14 <1 year in this NICU, 2e3 years in another NICU 1 19 19 7 7 Multiple phototherapy: when using more than one light source simultaneously (NICE, 2010). departments. Written informed consent was obtained from all the participants before inclusion in the study. There were no conflicts of interest that could affect the results. Results The interviewed nurses’ NICU experiences and choice of light sources are shown in Table 1. The fibreoptic blanket was new to NICU 2 and had not been incorporated into routine practice as well as in NICUs 1 and 3. NICU 2 had only one fibreoptic blanket available, whereas NICU 1 had two and NICU 3 had several blankets. The most frequently used types of equipment were BiliSoftª (fibreoptic) and NeoBlueª or BiliCompactª (conventional). The nurses did not comment on the type of light (LED, fluorescent, halogen, etc.). babies if she knew it was effective. Nurses A and B had conducted a literature review and had found that the fibreoptic blanket is effective if a sufficient amount of the body surface is exposed to light. They preferred fibreoptic blankets for preterm but not necessarily for full-term babies. For treating full-term infants, the nurses considered whether the blanket could cover the infant, the bilirubin level and the infant’s comfort. Nurse D expressed her opinion: “Conventional is very effective, maybe even more effective.” Nurse C indicated: “If the efficacy is better, the advantage is a shorter time of the light treatment.” The two nurses at NICU 3 believed the fibreoptic blanket was as effective as conventional therapy, and they no longer used conventional therapy. Nurse F said: Uncertainty about the efficacy of fibreoptic blankets “It does not take many days to lower bilirubin level. The efficacy is fine.” The nurses from NICUs 1 and 2 agreed that the combination of conventional and fibreoptic light sources was a good option for delivering multiple phototherapy. For single-light1 phototherapy, the experiences varied between the four nurses. For example, Nurse C stated: “Sometimes it seems to work fine, other times it doesn’t”. She would use the blanket for most of the preterm and full-term She also indicated that the treatment time had decreased after the unit started using BiliSoftª, which is larger than the previously used BiliBlanketª. When required, they used two blankets; over and underneath the infant. 1 Single-light phototherapy uses one light source. Differences in infant comfort All six nurses reported that infants frequently cried, were uncomfortable or were stressed under conventional phototherapy. Nurse E stated: Nurses’ experiences using conventional versus fibreoptic phototherapy “The babies are naked, unprotected and alone.” According to several nurses, the infants receive a shorter period of phototherapy if breaks have to be taken to comfort them. All six nurses found that infants were more satisfied in blankets than under conventional treatment because the baby can be wrapped with the blanket, which forms a comfortable nest around the baby, and the blanket promotes the foetal position. Nurse F stated: “When using the fibreoptic blanket, the infant is satisfied and sleeps well in a comfortable position.” Nurse A gave an example of a baby who cried constantly during conventional phototherapy. The only place he was happy was in his mother’s arms or when breastfeeding. The conventional treatment was interrupted for a long time until a fibreoptic blanket was placed under him as he lay in his mother’s arms. Differences in parent satisfaction Several nurses described phototherapy as a situation that is difficult for parents; several had seen parents crying. Nurse D said: “Parents are really worried about their baby’s situation, even if it is a situation we are not concerned about! They often express their worries more intensely than in other situations.” She found this peculiar because phototherapy is usually an uncomplicated treatment, and she thought this distress might relate to the mother’s hormonal imbalance or unmet expectations. Several nurses described the parental feeling of distance or a dramatic image of a naked child with eyes covered under conventional light, and stated that these feelings might harm the attachment process. All six nurses believed that the fibreoptic blanket allowed the infant to be closer to the parent. Nurse E said: “I think the parents are happy when the child is close to them.” She had heard parents saying with surprise: “Is this really possible?” Two of the nurses (E and F) had seen infants spend almost all day in kangaroo care (KC) combined with phototherapy. They described this as valuable for parenteinfant bonding and indicated that it was in accordance with the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Nurses B, C and E felt that the combination of KC and phototherapy was not accomplished as often as it could be. Nurse E 111 suggested that letting the infant remain in bed or the incubator may be more convenient for the nurse. Some nurses were not aware of the possibility that KC could be combined with phototherapy. Nurse C said: “Regarding interaction and FCC, the fibreoptic blanket is preferred. It’s not easy to provide skin-to-skin contact, but at least the parents can hold the baby in their arms.” Possibility of harm from phototherapy The nurses all described the blue light as uncomfortable, and they turned it off during interventions. Eye protection for the infant was used in both conventional and fibreoptic phototherapy. Several nurses reported that the eye protection fell off easily or slipped away from the eyes, but the situation was better when using a fibreoptic blanket. Nurse B stated: “The eye protection does not slide away from the eyes as often as in conventional therapy, because the infant is calmer.” Some nurses explained that they used sheets or curtains as shields, but none of the units provided eye protection for the parents or nurses. Several nurses described the conventional light as glaring and stated that long-term exposure was “painful or uncomfortable”. All agreed that light from blankets is much more comfortable than conventional light. The blanket might be a challenge for the baby’s skincare because the blanket is quite hard, and some nurses noted that a baby’s skin can become clammy. Nurses B and C chose the conventional device for infants with immature skin. The nurses sometimes discussed whether phototherapy might not be as safe as assumed: “How harmless is the light for the fragile, transparent skin and the cells?” (Nurse F) Discussion The nurses described their positive experiences with fibreoptic devices, such as the promotion of infant comfort, parent satisfaction, bonding, breastfeeding, KC, and NIDCAP. However, some nurses had concerns about the efficacy of fibreoptic blankets and the possibility of harm from both fibreoptic and conventional phototherapy. 112 The present study revealed that one of the advantages of fibreoptic phototherapy is that infants seem to be satisfied. All six nurses had experience with crying, stressed or uncomfortable infants during conventional phototherapy. This has been shown in research on mothers’ experiences (Hannon et al., 2001). However, infant behaviour is rarely the focus of research on phototherapy, despite the short- and long-term importance. Stressed preterm infants have an increased risk of haemorrhage in the first days after birth (Volpe, 2008), which is often concurrent with beginning phototherapy. Several nurses perceived phototherapy as being traumatic for parents. Previous studies have reported similar results; for example, mothers have reported the first days of having an infant with neonatal jaundice as “very frustrating”, “torture”, “gruelling”, “draining”, “brutal”, “awful” and “overwhelming” (Brethauer and Carey, 2010). The nurses in our study proposed that unmet expectations, maternal hormonal imbalance, a feeling of distance, worries about hazards and the image of a naked baby might explain the reactions of parents. This is consistent with previous studies that have described mothers’ struggles with guilt, distress, breastfeeding problems, misunderstanding and lack of information (Hannon et al., 2001). The feeling of distance and lack of parentechild bonding are emphasized in several studies (Hannon et al., 2001; Truman, 2003). These feelings and reactions highlight the importance of the finding in our study that the fibreoptic blanket helps to promote the parentechild interaction, breastfeeding and parent satisfaction. Some nurses also noted that KC is possible and is favourable during phototherapy, although Nurses C and D did not use KC with fibreoptic phototherapy. As indicated by Nurse C, this may be because of uncertainty and lack of knowledge, which have been shown to be barriers to the delivery of KC (Flynn and LeahyWarren, 2010). Nurse B suggested that not using KC with fibreoptic phototherapy might reflect a general lack of KC implementation in the unit. This is a well-known challenge in NICUs (Jesney, 2015). Nurses may feel that it is more convenient or feel more in control by keeping the infant in a bed or incubator (Ludington-Hoe, 2011). The nurses had different views on the duration needed for treatment. Some nurses indicated that conventional phototherapy may be more effective and has the advantage of requiring a shorter period of light treatment. Infants who receive fibreoptic treatment may need prolonged treatment (Mills and Tudehope, 2001). On the other hand, several nurses experienced that crying infants received A.M. Føreland et al. many breaks from conventional phototherapy and that the bilirubin level did not decrease to the extent desired. Treatment was seldom interrupted when using fibreoptic blankets because the baby was satisfied or easier to calm. This is not shown in previous research. The nurses in NICU 3 had found that the blankets worked well enough to enable them to discontinue the use of conventional devices. All nurses highlighted the ability to lower bilirubin level as the most important quality of a phototherapy device; however, this goal could be achieved in different ways. Nurses described the blue light from phototherapy as causing discomfort. The eye protection slipped off easily, and they worried about harm to the infants’ eyes. This problem is discussed by recent studies that have focused on the adverse effects of blue light (Xiong et al., 2011; Csoma et al., 2011). Phototherapy might not be as harmless as previously thought. None of the three NICUs used eye shields for parents or nurses, even though this is recommended by device manufacturers. Protective glasses for parents and nurses might be made available in all NICUs. However, this is of minor importance when using fibreoptic blankets. According to the findings of our study, light from a fibreoptic blanket is less uncomfortable and is easier to block. Eye shields are still needed for the infant, but they do not slip away as often when fibreoptic blankets are used because the infant is calmer. Nurses were also concerned about the use of phototherapy for preterm infants because of their immature skin and the possibility of causing cell injury. Research indicates that phototherapy may increase mortality among the most immature infants (Tyson et al., 2012), and this finding may be related to the thin skin through which the light penetrates readily and more deeply (Maisels et al., 2012). Extremely low birth weight infants treated with fibreoptic blankets are at lower risk of patent ductus arteriosus or death (Morris et al., 2013). Experts are discussing adverse effects (Hansen, 2012), and it might influence future recommendations for the use of fibreoptic versus conventional light sources. There are many types of conventional and fibreoptic devices and differences in their use and guidelines for use around the world. The Norwegian guidelines recommend fibreoptic devices for multiple phototherapy treatment but not for use as a single device (Bratlid et al., 2011). Only one of the nurses (Nurse D) acted in accordance with this guideline. NICU 3 used a fibreoptic device as the only choice and used two blankets for infants with a high bilirubin level. The guidelines of the American Academy of Pediatrics (2004) for newborns 35 Nurses’ experiences using conventional versus fibreoptic phototherapy weeks state that fibreoptic devices deliver enough output to be effective for standard phototherapy but not when the bilirubin level requires “intensive”2 phototherapy. These guidelines also state that two or three pads may be needed because the pads cover only a small surface area. The British guidelines state that babies <37 weeks may receive fibreoptic phototherapy unless the serum bilirubin level increases rapidly (NICE, 2010). The guidelines differ between countries despite being based on research. Mills and Tudehope (2001) concluded that fibreoptic phototherapy was equally as effective as conventional phototherapy in preterm infants but less effective in full-term infants, and the combined use of both device is most effective. A study of preterm babies <31 weeks (Romagnoli et al., 2006) confirmed these results. However, according to Morris et al. (2013), fibreoptic blankets have the highest mean irradiance level but are not effective for extremely lowbirthweight infants. The differences in the use of devices between the nurses in our study reflect the diversity in guidelines and research findings. The use of six informants may limit how representative this study is; however, the findings represent practice from three different NICUs and 91 years of experience from nurses using phototherapy. Our findings indicate a need for more research on and discussion about phototherapy. Questions remain about whether fibreoptic blankets will be the only devices and, if not, how caregivers should make the best choice about the configuration and use of conventional and fibreoptic equipment. The importance of infant satisfaction and parent bonding in conjunction with the choice of light source should also be investigated. Conclusion This study describes the perceptions of six nurses from three different NICUs about their experiences with conventional overhead versus fibreoptic blanket phototherapy. Positive experiences with fibreoptic devices were found, such as the promotion of infant comfort, parent satisfaction, bonding, breastfeeding, KC and NIDCAP. However, some nurses and their colleagues had concerns about the efficacy of fibreoptic blankets and the 2 Intensive phototherapy is defined as irradiance of at least 30 mW/cm2 per nm in the 430e490 nm band to deliver light to as much of the infant’s surface area as possible (AAP, 2004). 113 possibility of harm caused by both fibreoptic and conventional phototherapy. When decrease in bilirubin level was considered sufficient, blankets were the nurses’ preferred light source, compared with conventional overhead phototherapy because of the ability to facilitate infant comfort and parentechild interaction. Conflicts of interest None. 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