Rita Pickler - Academia.edu (original) (raw)

Papers by Rita Pickler

Research paper thumbnail of Missed Oral Feeding Opportunities and Preterm Infants' Time to Achieve Full Oral Feedings and Neonatal Intensive Care Unit Discharge

American Journal of Perinatology, Mar 28, 2014

To examine the association of missed oral feeding opportunities among preterm infants with achiev... more To examine the association of missed oral feeding opportunities among preterm infants with achievement of full oral feedings and length of hospitalization. A secondary analysis of clinical trial data was conducted. Study infants included in the analysis (N = 89) were randomized to one of four standardized feeding progression approaches; detailed records on all feedings were maintained. The proportion of oral feeding opportunities reported as missed due to factors unrelated to the infant's clinical condition was calculated for each infant. The proportion of missed oral feeding opportunities per infant ranged from 0 to 0.12; 30 infants experienced one or more missed oral feeding opportunity. Each 1% increase in the proportion of missed oral feeding opportunities extended the time to achieve full oral feeding by 1.45 days (p = 0.007) and time to discharge by 1.36 days (p = 0.047). Preterm infants' missed oral feeding opportunities may adversely affect feeding outcomes and extend hospitalization.

Research paper thumbnail of Endotracheal Suctioning in Preterm Infants Using Four‐Handed versus Routine Care

Journal of Obstetric, Gynecologic, & Neonatal Nursing, 2013

Objective-To evaluate the effect of four-handed care on preterm infants' physiologic and behavior... more Objective-To evaluate the effect of four-handed care on preterm infants' physiologic and behavioral responses to and recovery from endotracheal suctioning versus routine endotracheal (ETT) suctioning. Design-Randomized crossover design with infants as their own controls. Setting-Single-family-room newborn intensive care unit in an academic health center. Participants-Ten intubated infants on conventional ventilation with inline suctioning who were fewer than 37 weeks gestation at birth, and less than one week of age. Methods-Each infant was observed twice on a single day. One observation involved routine ETT suctioning and one involved four-handed care. Physiologic and behavioral response data were collected. Results-No differences were noted when comparing baseline heart rate (HR) or oxygen saturation (SpO 2) data to those obtained during and after suctioning while in the routine care condition. In the four-handed care condition, mean SpO 2 increased from preobservation 95.49 to during observation saturation 97.75 (p = .001). Salivary cortisol levels did not differ between groups at baseline or postsuctioning. No significant difference in behavior state was observed between the two conditions. More stress and defense behaviors occurred postsuctioning when infants received routine care as opposed to four-handed care (p = .001) and more self-regulatory

Research paper thumbnail of Perinatal Stress, Fatigue, Depressive Symptoms, and Immune Modulation in Late Pregnancy and One Month Postpartum

The Scientific World Journal, 2014

Stress and fatigue are common complaints of pregnant and postpartum women as is depression. These... more Stress and fatigue are common complaints of pregnant and postpartum women as is depression. These symptoms may be related to immunomodulation. However, few studies have examined these relationships. The aim of this study was to examine the relationships among stress, fatigue, depression, and cytokines as markers of immune modulation in prenatal and postpartum women. Women completed questionnaires and gave blood samples during late pregnancy and again at 4-6 weeks postpartum. Blood was analyzed for cytokines as measures of immune modulation. Stress, fatigue, and depression were experienced at moderately high levels, with higher levels of fatigue and depression in the postpartum but higher stress in the prenatal period. Levels of several cytokines were increased in the postpartum over the prenatal period. Stress and depression were related in the prenatal period and stress, depression, and fatigue were related in the postpartum. While various cytokines were related to each other in both periods, only stress was related to MIP-1 , a cytokine that may be important for childbirth processes. More studies, especially longitudinal and interventional studies, are needed to increase our knowledge about etiology, patterns, symptoms, factors, and management of maternal distress. The search for reliable biomarkers for at-risk mothers remains a priority.

Research paper thumbnail of Caring for a Preterm Infant at Home

Journal of Perinatal & Neonatal Nursing, Oct 1, 2013

The purpose of this phenomenological study was to examine the experiences of mothers of preterm i... more The purpose of this phenomenological study was to examine the experiences of mothers of preterm infants during the first 6 months at home following discharge from a neonatal intensive care unit (NICU). A purposeful sample of 8 mothers was gathered and interviews were conducted over a 4-month period. Each interview was audio recorded and took place in the study participant's home or another place of her choosing. Interviews were transcribed verbatim and analyzed independently with themes being identified and organized for each participant. From these analyses, the themes of fear, exhaustion, determination, and thankfulness were identified as being common to all study participants and became the basis for developing the essence of the phenomenon. The essence of this experience for these mothers was their resolve to do whatever was necessary to ensure the best possible outcomes for their infants. The data gathered from these personal interviews will serve to further inform our understanding of this important time from the perspective of those who experienced it, as well as aid in the design of interventions to address the specific needs of these mothers prior to NICU discharge.

Research paper thumbnail of Effects of stress and social support on postpartum health of Chinese mothers in the United States

Research in Nursing & Health, Dec 1, 2009

Research paper thumbnail of Parental Experience Learning to Feed Their Preterm Infants

Advances in Neonatal Care, Oct 1, 2014

Purpose-Although extensive research has been conducted on preterm infant oral feeding, few invest... more Purpose-Although extensive research has been conducted on preterm infant oral feeding, few investigations have examined parents' experiences learning to orally feed their preterm infant while in the neonatal intensive care unit (NICU). As such, the aim of this study was to explore parental learning experiences to gain a better understanding of the process parents' use in learning to feed their preterm infant. Subjects-Parents included in the investigation were18 years of age or older with a medically stable preterm infant that was less than 36 weeks gestational age at birth, free of congenital malformations, and feeding orally. Design-This investigation used hermeneutic phenomenology to explore the depth and richness of parental experience with the process of learning to orally feed their preterm infant. Methods-Participants were recruited from a university affiliated women's hospital with a Level III NICU. Purposive sampling was used to ensure that all participants were familiar with the experience of interest. Data collection consisted of personal interviews conducted in a private consultation room located within the NICU. In instances where both the infant's mother and father chose to participate, the interviews were conducted separately on the same day. Main Outcome measures-Twelve mothers and eight fathers participated in semi-structured interviews. For eight mothers and six fathers, this was their first child. This was the first preterm infant for all participants. From the parental experience three themes were identified: an emotional experience; learn as you go; and it's technical. Principal Results-Parents noted that feeding encompassed both positive as well as negative emotions, that learning was a process that nurses played an instrumental role in, and that feeding a preterm infant could be very technical requiring extra skills for feeding success.

Research paper thumbnail of A research protocol for testing relationships between nurse workload, missed nursing care and neonatal outcomes: the neonatal nursing care quality study

Journal of Advanced Nursing, Oct 29, 2014

A research protocol for testing relationships between nurse workload, missed nursing care and neo... more A research protocol for testing relationships between nurse workload, missed nursing care and neonatal outcomes: the neonatal nursing care quality study.

Research paper thumbnail of Behavioral Observation of Infants With Life-Threatening or Life-Limiting Illness in the Neonatal Intensive Care Unit

Nursing Research, Jun 17, 2020

Background: Infants in the neonatal intensive care unit experience aversive stimuli that cause pa... more Background: Infants in the neonatal intensive care unit experience aversive stimuli that cause pain and distress. Maintaining adequate relief from pain and distress is challenging because of infants' varying ages and stages of development and their nonverbal status. Thus, pain and distress must be interpreted by a healthcare provider or other proxy from their own observations or perceptions. There is no standard research or clinical measure for pain and distress in infants. Objective: The purpose of this analysis was to evaluate the use of the COMFORT Behavior (COMFORT-B) Scale as a measure of pain and distress in infants diagnosed with life-threatening or life-limiting illnesses in the neonatal intensive care unit in comparison with the nurse-documented Neonatal Pain, Agitation and Sedation Scale; the infants' Technology Dependence Scale; and the mothers' report of total perceived symptom scores. Methods: Infants diagnosed with life-threatening or life-limiting illnesses and hospitalized in a Level IV neonatal intensive care unit in the Midwestern United States and their parents were included. Measurement of pain and distress in infants was collected weekly from enrollment through 12 weeks or until discharge, whichever occurred first. Observations for the COMFORT-B Scale were conducted before and after standard caregiving activities. Pearson r correlations were used to compare means between pain and distress, technology dependence, and mothers' total perceived symptom scores over time. Results: Data from 78 infants (46 male and 32 female infants) of ages 23-41 weeks of gestation at birth were analyzed. No correlations were found among the COMFORT-B Scale; the Neonatal Pain, Agitation and Sedation Scale; and mothers' total perceived symptom scores. Moderate correlations were found among the Technology Dependence Scale; mothers' total perceived symptom scores; and the Neonatal Pain, Agitation and Sedation Scale. Discussion: Performing COMFORT-B observations can be challenging, and it is unclear whether the information obtained from the COMFORT-B Scale added to the assessment of the infant's pain and distress that is typically recorded in the health record or from parents. Further evaluation is needed to determine if it is more reliable to collect the Neonatal Pain, Agitation and Sedation Scale scores rather than conduct observations using the COMFORT-B Scale in studies of infants with life-threatening and life-limiting illnesses in the neonatal intensive care unit.

Research paper thumbnail of Early Inflammatory Measures and Neurodevelopmental Outcomes in Preterm Infants

Nursing Research, Jun 3, 2020

Background: Inflammation may be an important predictor of long-term neurodevelopment in preterm i... more Background: Inflammation may be an important predictor of long-term neurodevelopment in preterm infants. The identification of specific inflammatory biomarkers that predict outcomes is an important research goal. Objectives: The purpose of this analysis was to identify associations between an early measure of inflammation and neurodevelopment in very preterm infants and to identify differences in the relationship between inflammation and neurodevelopment based on infant gender and race. Methods: We conducted a secondary analysis of data from a randomized controlled trial of a caregiving intervention for preterm infants born less than 33 weeks postmenstrual age. Plasma was collected with a clinically indicated laboratory draw by neonatal intensive care unit nurses and analyzed by multiplex assay for cytokines, chemokines, and growth factors. Neurobehavior was assessed by research nurses at the time of discharge from the neonatal intensive care unit using the motor development and vigor and alertness/orientation clusters from the Neurobehavioral Assessment of the Preterm Infant. Neurodevelopment was assessed at 6 months corrected age by the developmental specialist in the hospital's neonatal follow-up clinic using the Bayley Scales of Infant Development, Third Edition. We used linear regressions to estimate the effect of cytokine levels on neurodevelopment and allowed the effects to differ by infant gender and race. Results: In a sample of 62 preterm infants with discharge neurobehavioral assessments and a sample of 40 preterm infants with 6-month neurodevelopmental assessments, we found inconsistent associations between single-time point inflammatory measures and neurobehavior or neurodevelopment in analyses of the total sample. However, regressions with interactions revealed effects for multiple inflammatory measures on early neurobehavior and neurodevelopment that differed by infant gender and race. Discussion: Although early single-time point measures of inflammation may be insufficient to predict neurodevelopment for all preterm infants, the effect of inflammation appears to differ by infant gender and race. These demographic factors may be important considerations for future studies of inflammation and neurodevelopment as well was the development of future interventions to optimize outcomes.

Research paper thumbnail of Gloving and Touch Practices of Neonatal Nurses

Journal of Perinatal & Neonatal Nursing, 2022

Supplemental Digital Content is Available in the Text. Positive tactile experiences in the newbor... more Supplemental Digital Content is Available in the Text. Positive tactile experiences in the newborn period are critical to normal sensory development. Universal gloving in the neonatal intensive care unit has become a controversial issue in neonatal nursing practice. Intended to prevent infection among neonatal patients, universal gloving also hinders the provision of human touch. The purpose of this survey study was to (1) describe gloving policies in neonatal intensive care units, and (2) describe the gloving and touch practices of neonatal nurses and identify associations between these practices and demographic characteristics. The investigators developed a 19-question, anonymous survey. The survey link was distributed through the National Association of Neonatal Nurses' social media and newsletter. Of the 137 responses, only 22.1% of nurses reported unit policy requiring universal gloving. While nurses reported some ambiguity about gloving policies, surveyed nurses commonly used gloves when performing general care activities. Institutional gloving policies varied in this geographically diverse sample, but routine, bare-handed touch was an uncommon practice among neonatal nurses. Research evidence is needed to guide nursing practice and inform policy decisions regarding glove use in the neonatal intensive care unit.

Research paper thumbnail of Measures of Stress Exposure for Hospitalized Preterm Infants

Nursing Research, 2020

Background Extended hospitalization in neonatal intensive care units subjects preterm infants to ... more Background Extended hospitalization in neonatal intensive care units subjects preterm infants to multiple stress exposures that affect long-term cognitive functioning, motor development, and stress reactivity. Measurement of stress exposure is challenging with multiple measures of stress exposure in use, including counts of skin-breaking or invasive procedures or counts of noxious sensory exposures. Objectives The purpose of this analysis was to compare measures of stress exposure commonly used by researchers and to determine the predictive validity of these measures for early neurobehavior. We accomplished this objective through the following specific aims: (a) describe the stress exposures of preterm infants in the first 2 weeks of life, (b) determine the correlations among measures of stress exposure, and (c) compare the predictive validity of measures of stress exposure for early neurobehavior. Methods Very preterm infants born between 28 and 31 weeks postmenstrual age were enro...

Research paper thumbnail of Behavioral Observation of Infants With Life-Threatening or Life-Limiting Illness in the Neonatal Intensive Care Unit

Nursing Research, 2020

Background: Infants in the neonatal intensive care unit experience aversive stimuli that cause pa... more Background: Infants in the neonatal intensive care unit experience aversive stimuli that cause pain and distress. Maintaining adequate relief from pain and distress is challenging because of infants' varying ages and stages of development and their nonverbal status. Thus, pain and distress must be interpreted by a healthcare provider or other proxy from their own observations or perceptions. There is no standard research or clinical measure for pain and distress in infants. Objective: The purpose of this analysis was to evaluate the use of the COMFORT Behavior (COMFORT-B) Scale as a measure of pain and distress in infants diagnosed with life-threatening or life-limiting illnesses in the neonatal intensive care unit in comparison with the nurse-documented Neonatal Pain, Agitation and Sedation Scale; the infants' Technology Dependence Scale; and the mothers' report of total perceived symptom scores. Methods: Infants diagnosed with life-threatening or life-limiting illnesses and hospitalized in a Level IV neonatal intensive care unit in the Midwestern United States and their parents were included. Measurement of pain and distress in infants was collected weekly from enrollment through 12 weeks or until discharge, whichever occurred first. Observations for the COMFORT-B Scale were conducted before and after standard caregiving activities. Pearson r correlations were used to compare means between pain and distress, technology dependence, and mothers' total perceived symptom scores over time. Results: Data from 78 infants (46 male and 32 female infants) of ages 23-41 weeks of gestation at birth were analyzed. No correlations were found among the COMFORT-B Scale; the Neonatal Pain, Agitation and Sedation Scale; and mothers' total perceived symptom scores. Moderate correlations were found among the Technology Dependence Scale; mothers' total perceived symptom scores; and the Neonatal Pain, Agitation and Sedation Scale. Discussion: Performing COMFORT-B observations can be challenging, and it is unclear whether the information obtained from the COMFORT-B Scale added to the assessment of the infant's pain and distress that is typically recorded in the health record or from parents. Further evaluation is needed to determine if it is more reliable to collect the Neonatal Pain, Agitation and Sedation Scale scores rather than conduct observations using the COMFORT-B Scale in studies of infants with life-threatening and life-limiting illnesses in the neonatal intensive care unit.

Research paper thumbnail of Association of Nurse Workload With Missed Nursing Care in the Neonatal Intensive Care Unit

JAMA pediatrics, Jan 12, 2018

Quality improvement initiatives demonstrate the contribution of reliable nursing care to gains in... more Quality improvement initiatives demonstrate the contribution of reliable nursing care to gains in clinical and safety outcomes in neonatal intensive care units (NICUs); when core care is missed, outcomes can worsen. To evaluate the association of NICU nurse workload with missed nursing care. A prospective design was used to evaluate associations between shift-level workload of individual nurses and missed care for assigned infants from March 1, 2013, through January 31, 2014, at a 52-bed level IV NICU in a Midwestern academic medical center. A convenience sample of registered nurses who provided direct patient care and completed unit orientation were enrolled. Nurses reported care during each shift for individual infants whose clinical data were extracted from the electronic health record. Data were analyzed from January 1, 2015, through August 13, 2018. Workload was assessed each shift with objective measures (infant-to-nurse staffing ratio and infant acuity scores) and a subjectiv...

Research paper thumbnail of Patterned feeding experience for preterm infants: study protocol for a randomized controlled trial

Trials, 2015

Background: Neurobehavioral disabilities occur in 5-15 % of preterm infants with an estimated 50-... more Background: Neurobehavioral disabilities occur in 5-15 % of preterm infants with an estimated 50-70 % of very low birth weight preterm infants experiencing later dysfunction, including cognitive, behavioral, and social delays that often persist into adulthood. Factors implicated in poor neurobehavioral and developmental outcomes are hospitalization in the neonatal intensive care unit (NICU) and inconsistent caregiving patterns. Although much underlying brain damage occurs in utero or shortly after birth, neuroprotective strategies can stop lesions from progressing, particularly when these strategies are used during the most sensitive periods of neural plasticity occurring months before term age. The purpose of this randomized trial is to test the effect of a patterned feeding experience on preterm infants' neurobehavioral organization and development, cognitive function, and clinical outcomes. Methods: This trial uses an experimental, longitudinal, 2-group design with 120 preterm infants. Infants are enrolled within the first week of life and randomized to an experimental group receiving a patterned feeding experience from the first gavage feeding through discharge or to a control group receiving usual feeding care experience. The intervention involves a continuity of tactile experiences associated with feeding to train and build neuronal networks supportive of normal infant feeding experience. Primary outcomes are neurobehavioral organization as measured by Neurobehavioral Assessment of the Preterm Infant at 3 time points: the transition to oral feedings, NICU discharge, and 2 months corrected age. Secondary aims are cognitive function measured using the Bayley Scales of Infant and Toddler Development, Third Edition at 6 months corrected age, neurobehavioral development (sucking organization, feeding performance, and heart rate variability), and clinical outcomes (length of NICU stay and time to full oral feeding). The potential effects of demographic and biobehavioral factors (perinatal events and conditions of maternal or fetal/ newborn origin and immunologic and genetic biomarkers) on the outcome variables will also be considered. Discussion: Theoretically, the intervention provided at a critical time in neurologic system development and associated with a recurring event (feeding) should enhance neural connections that may be important for later development, particularly language and other cognitive and neurobehavioral organization skills. Trial registration: NCT01577615 11 April 2012.

Research paper thumbnail of Perinatal stress, fatigue, depressive symptoms, and immune modulation in late pregnancy and one month postpartum

TheScientificWorldJournal, 2014

Stress and fatigue are common complaints of pregnant and postpartum women as is depression. These... more Stress and fatigue are common complaints of pregnant and postpartum women as is depression. These symptoms may be related to immunomodulation. However, few studies have examined these relationships. The aim of this study was to examine the relationships among stress, fatigue, depression, and cytokines as markers of immune modulation in prenatal and postpartum women. Women completed questionnaires and gave blood samples during late pregnancy and again at 4-6 weeks postpartum. Blood was analyzed for cytokines as measures of immune modulation. Stress, fatigue, and depression were experienced at moderately high levels, with higher levels of fatigue and depression in the postpartum but higher stress in the prenatal period. Levels of several cytokines were increased in the postpartum over the prenatal period. Stress and depression were related in the prenatal period and stress, depression, and fatigue were related in the postpartum. While various cytokines were related to each other in bo...

Research paper thumbnail of Measuring maternal responsiveness

The ABNF journal : official journal of the Association of Black Nursing Faculty in Higher Education, Inc, 2007

The purpose of this study was to review current research studies examining maternal responsivenes... more The purpose of this study was to review current research studies examining maternal responsiveness to locate self-report instruments, and to identify variables in these self-report instruments used to describe maternal responsiveness. The electronic databases, Medline, PsychLit, SocLit, and Cinahl were searched with the following key words: maternal responsiveness, maternal sensitivity, maternal attachment, maternal response, and responsiveness. Articles were obtained, assessed, and agreed upon for their usefulness to the study by the researcher and research assistant. Criteria included: articles must include key word, maternal responsiveness, in the title or a self-report instrument measuring maternal responsiveness. Fifty-two eligible studies were identified from the literature, read by two reviewers and both reviewers confirmed its applicability. All included studies were summarized in tabular form. References with the key words in the title were extracted from the literature to ...

Research paper thumbnail of A research protocol for testing relationships between nurse workload, missed nursing care and neonatal outcomes: the neonatal nursing care quality study

Journal of Advanced Nursing, 2014

AimWe describe an innovative research protocol to test the role of missed nursing care as a media... more AimWe describe an innovative research protocol to test the role of missed nursing care as a mediator of the association between nurse workload and patient outcomes in the neonatal intensive care unit.BackgroundIncreases in nurses' workloads are associated with adverse patient outcomes in neonatal intensive care settings. Missed nursing care is a frequently hypothesized explanation for the association between workload and outcomes. Few studies to date have tested missed care as a variable that mediates the workload–outcomes relationship.DesignWe use a longitudinal, observational study design.MethodsWe will recruit approximately 125 nurses (80% of target population) providing direct patient care in one neonatal intensive care unit. Four, 6‐week data collection cycles occur over 1 year. At the end of every shift, nurses report on their workloads and the frequency with which specific patient care activities were missed for each infant cared for during the shift. Infant‐specific nurs...

Research paper thumbnail of A descriptive study of nurse‐reported missed care in neonatal intensive care units

Journal of Advanced Nursing, 2014

AimsThe aims of this study are to describe: (1) the frequency of nurse‐reported missed care in ne... more AimsThe aims of this study are to describe: (1) the frequency of nurse‐reported missed care in neonatal intensive care units; and (2) nurses’ reports of factors contributing to missed care on their last shift worked.BackgroundMissed nursing care, or necessary care that is not delivered, is increasingly cited as a contributor to adverse patient outcomes. Previous studies highlight the frequency of missed nursing care in adult settings; the occurrence of missed nursing care in neonatal intensive care units is unknown.DesignA descriptive analysis of neonatal nurses’ self‐reports of missed care using data collected through a cross‐sectional web‐based survey.MethodsA random sample of certified neonatal intensive care nurses in seven states was invited to participate in the survey in April 2012. Data were collected from nurses who provide direct patient care in a neonatal intensive care unit (n = 230). Descriptive statistics constituted the primary analytic approach.ResultsNurses reported...

Research paper thumbnail of Parental Experience Learning to Feed Their Preterm Infants

Advances in Neonatal Care, 2014

Purpose-Although extensive research has been conducted on preterm infant oral feeding, few invest... more Purpose-Although extensive research has been conducted on preterm infant oral feeding, few investigations have examined parents' experiences learning to orally feed their preterm infant while in the neonatal intensive care unit (NICU). As such, the aim of this study was to explore parental learning experiences to gain a better understanding of the process parents' use in learning to feed their preterm infant. Subjects-Parents included in the investigation were18 years of age or older with a medically stable preterm infant that was less than 36 weeks gestational age at birth, free of congenital malformations, and feeding orally. Design-This investigation used hermeneutic phenomenology to explore the depth and richness of parental experience with the process of learning to orally feed their preterm infant. Methods-Participants were recruited from a university affiliated women's hospital with a Level III NICU. Purposive sampling was used to ensure that all participants were familiar with the experience of interest. Data collection consisted of personal interviews conducted in a private consultation room located within the NICU. In instances where both the infant's mother and father chose to participate, the interviews were conducted separately on the same day. Main Outcome measures-Twelve mothers and eight fathers participated in semi-structured interviews. For eight mothers and six fathers, this was their first child. This was the first preterm infant for all participants. From the parental experience three themes were identified: an emotional experience; learn as you go; and it's technical. Principal Results-Parents noted that feeding encompassed both positive as well as negative emotions, that learning was a process that nurses played an instrumental role in, and that feeding a preterm infant could be very technical requiring extra skills for feeding success.

Research paper thumbnail of Caring for a Preterm Infant at Home

Journal of Perinatal & Neonatal Nursing, 2013

The purpose of this phenomenological study was to examine the experiences of mothers of preterm i... more The purpose of this phenomenological study was to examine the experiences of mothers of preterm infants during the first 6 months at home following discharge from a neonatal intensive care unit (NICU). A purposeful sample of 8 mothers was gathered and interviews were conducted over a 4-month period. Each interview was audio recorded and took place in the study participant's home or another place of her choosing. Interviews were transcribed verbatim and analyzed independently with themes being identified and organized for each participant. From these analyses, the themes of fear, exhaustion, determination, and thankfulness were identified as being common to all study participants and became the basis for developing the essence of the phenomenon. The essence of this experience for these mothers was their resolve to do whatever was necessary to ensure the best possible outcomes for their infants. The data gathered from these personal interviews will serve to further inform our understanding of this important time from the perspective of those who experienced it, as well as aid in the design of interventions to address the specific needs of these mothers prior to NICU discharge.

Research paper thumbnail of Missed Oral Feeding Opportunities and Preterm Infants' Time to Achieve Full Oral Feedings and Neonatal Intensive Care Unit Discharge

American Journal of Perinatology, Mar 28, 2014

To examine the association of missed oral feeding opportunities among preterm infants with achiev... more To examine the association of missed oral feeding opportunities among preterm infants with achievement of full oral feedings and length of hospitalization. A secondary analysis of clinical trial data was conducted. Study infants included in the analysis (N = 89) were randomized to one of four standardized feeding progression approaches; detailed records on all feedings were maintained. The proportion of oral feeding opportunities reported as missed due to factors unrelated to the infant's clinical condition was calculated for each infant. The proportion of missed oral feeding opportunities per infant ranged from 0 to 0.12; 30 infants experienced one or more missed oral feeding opportunity. Each 1% increase in the proportion of missed oral feeding opportunities extended the time to achieve full oral feeding by 1.45 days (p = 0.007) and time to discharge by 1.36 days (p = 0.047). Preterm infants' missed oral feeding opportunities may adversely affect feeding outcomes and extend hospitalization.

Research paper thumbnail of Endotracheal Suctioning in Preterm Infants Using Four‐Handed versus Routine Care

Journal of Obstetric, Gynecologic, & Neonatal Nursing, 2013

Objective-To evaluate the effect of four-handed care on preterm infants' physiologic and behavior... more Objective-To evaluate the effect of four-handed care on preterm infants' physiologic and behavioral responses to and recovery from endotracheal suctioning versus routine endotracheal (ETT) suctioning. Design-Randomized crossover design with infants as their own controls. Setting-Single-family-room newborn intensive care unit in an academic health center. Participants-Ten intubated infants on conventional ventilation with inline suctioning who were fewer than 37 weeks gestation at birth, and less than one week of age. Methods-Each infant was observed twice on a single day. One observation involved routine ETT suctioning and one involved four-handed care. Physiologic and behavioral response data were collected. Results-No differences were noted when comparing baseline heart rate (HR) or oxygen saturation (SpO 2) data to those obtained during and after suctioning while in the routine care condition. In the four-handed care condition, mean SpO 2 increased from preobservation 95.49 to during observation saturation 97.75 (p = .001). Salivary cortisol levels did not differ between groups at baseline or postsuctioning. No significant difference in behavior state was observed between the two conditions. More stress and defense behaviors occurred postsuctioning when infants received routine care as opposed to four-handed care (p = .001) and more self-regulatory

Research paper thumbnail of Perinatal Stress, Fatigue, Depressive Symptoms, and Immune Modulation in Late Pregnancy and One Month Postpartum

The Scientific World Journal, 2014

Stress and fatigue are common complaints of pregnant and postpartum women as is depression. These... more Stress and fatigue are common complaints of pregnant and postpartum women as is depression. These symptoms may be related to immunomodulation. However, few studies have examined these relationships. The aim of this study was to examine the relationships among stress, fatigue, depression, and cytokines as markers of immune modulation in prenatal and postpartum women. Women completed questionnaires and gave blood samples during late pregnancy and again at 4-6 weeks postpartum. Blood was analyzed for cytokines as measures of immune modulation. Stress, fatigue, and depression were experienced at moderately high levels, with higher levels of fatigue and depression in the postpartum but higher stress in the prenatal period. Levels of several cytokines were increased in the postpartum over the prenatal period. Stress and depression were related in the prenatal period and stress, depression, and fatigue were related in the postpartum. While various cytokines were related to each other in both periods, only stress was related to MIP-1 , a cytokine that may be important for childbirth processes. More studies, especially longitudinal and interventional studies, are needed to increase our knowledge about etiology, patterns, symptoms, factors, and management of maternal distress. The search for reliable biomarkers for at-risk mothers remains a priority.

Research paper thumbnail of Caring for a Preterm Infant at Home

Journal of Perinatal & Neonatal Nursing, Oct 1, 2013

The purpose of this phenomenological study was to examine the experiences of mothers of preterm i... more The purpose of this phenomenological study was to examine the experiences of mothers of preterm infants during the first 6 months at home following discharge from a neonatal intensive care unit (NICU). A purposeful sample of 8 mothers was gathered and interviews were conducted over a 4-month period. Each interview was audio recorded and took place in the study participant's home or another place of her choosing. Interviews were transcribed verbatim and analyzed independently with themes being identified and organized for each participant. From these analyses, the themes of fear, exhaustion, determination, and thankfulness were identified as being common to all study participants and became the basis for developing the essence of the phenomenon. The essence of this experience for these mothers was their resolve to do whatever was necessary to ensure the best possible outcomes for their infants. The data gathered from these personal interviews will serve to further inform our understanding of this important time from the perspective of those who experienced it, as well as aid in the design of interventions to address the specific needs of these mothers prior to NICU discharge.

Research paper thumbnail of Effects of stress and social support on postpartum health of Chinese mothers in the United States

Research in Nursing & Health, Dec 1, 2009

Research paper thumbnail of Parental Experience Learning to Feed Their Preterm Infants

Advances in Neonatal Care, Oct 1, 2014

Purpose-Although extensive research has been conducted on preterm infant oral feeding, few invest... more Purpose-Although extensive research has been conducted on preterm infant oral feeding, few investigations have examined parents' experiences learning to orally feed their preterm infant while in the neonatal intensive care unit (NICU). As such, the aim of this study was to explore parental learning experiences to gain a better understanding of the process parents' use in learning to feed their preterm infant. Subjects-Parents included in the investigation were18 years of age or older with a medically stable preterm infant that was less than 36 weeks gestational age at birth, free of congenital malformations, and feeding orally. Design-This investigation used hermeneutic phenomenology to explore the depth and richness of parental experience with the process of learning to orally feed their preterm infant. Methods-Participants were recruited from a university affiliated women's hospital with a Level III NICU. Purposive sampling was used to ensure that all participants were familiar with the experience of interest. Data collection consisted of personal interviews conducted in a private consultation room located within the NICU. In instances where both the infant's mother and father chose to participate, the interviews were conducted separately on the same day. Main Outcome measures-Twelve mothers and eight fathers participated in semi-structured interviews. For eight mothers and six fathers, this was their first child. This was the first preterm infant for all participants. From the parental experience three themes were identified: an emotional experience; learn as you go; and it's technical. Principal Results-Parents noted that feeding encompassed both positive as well as negative emotions, that learning was a process that nurses played an instrumental role in, and that feeding a preterm infant could be very technical requiring extra skills for feeding success.

Research paper thumbnail of A research protocol for testing relationships between nurse workload, missed nursing care and neonatal outcomes: the neonatal nursing care quality study

Journal of Advanced Nursing, Oct 29, 2014

A research protocol for testing relationships between nurse workload, missed nursing care and neo... more A research protocol for testing relationships between nurse workload, missed nursing care and neonatal outcomes: the neonatal nursing care quality study.

Research paper thumbnail of Behavioral Observation of Infants With Life-Threatening or Life-Limiting Illness in the Neonatal Intensive Care Unit

Nursing Research, Jun 17, 2020

Background: Infants in the neonatal intensive care unit experience aversive stimuli that cause pa... more Background: Infants in the neonatal intensive care unit experience aversive stimuli that cause pain and distress. Maintaining adequate relief from pain and distress is challenging because of infants' varying ages and stages of development and their nonverbal status. Thus, pain and distress must be interpreted by a healthcare provider or other proxy from their own observations or perceptions. There is no standard research or clinical measure for pain and distress in infants. Objective: The purpose of this analysis was to evaluate the use of the COMFORT Behavior (COMFORT-B) Scale as a measure of pain and distress in infants diagnosed with life-threatening or life-limiting illnesses in the neonatal intensive care unit in comparison with the nurse-documented Neonatal Pain, Agitation and Sedation Scale; the infants' Technology Dependence Scale; and the mothers' report of total perceived symptom scores. Methods: Infants diagnosed with life-threatening or life-limiting illnesses and hospitalized in a Level IV neonatal intensive care unit in the Midwestern United States and their parents were included. Measurement of pain and distress in infants was collected weekly from enrollment through 12 weeks or until discharge, whichever occurred first. Observations for the COMFORT-B Scale were conducted before and after standard caregiving activities. Pearson r correlations were used to compare means between pain and distress, technology dependence, and mothers' total perceived symptom scores over time. Results: Data from 78 infants (46 male and 32 female infants) of ages 23-41 weeks of gestation at birth were analyzed. No correlations were found among the COMFORT-B Scale; the Neonatal Pain, Agitation and Sedation Scale; and mothers' total perceived symptom scores. Moderate correlations were found among the Technology Dependence Scale; mothers' total perceived symptom scores; and the Neonatal Pain, Agitation and Sedation Scale. Discussion: Performing COMFORT-B observations can be challenging, and it is unclear whether the information obtained from the COMFORT-B Scale added to the assessment of the infant's pain and distress that is typically recorded in the health record or from parents. Further evaluation is needed to determine if it is more reliable to collect the Neonatal Pain, Agitation and Sedation Scale scores rather than conduct observations using the COMFORT-B Scale in studies of infants with life-threatening and life-limiting illnesses in the neonatal intensive care unit.

Research paper thumbnail of Early Inflammatory Measures and Neurodevelopmental Outcomes in Preterm Infants

Nursing Research, Jun 3, 2020

Background: Inflammation may be an important predictor of long-term neurodevelopment in preterm i... more Background: Inflammation may be an important predictor of long-term neurodevelopment in preterm infants. The identification of specific inflammatory biomarkers that predict outcomes is an important research goal. Objectives: The purpose of this analysis was to identify associations between an early measure of inflammation and neurodevelopment in very preterm infants and to identify differences in the relationship between inflammation and neurodevelopment based on infant gender and race. Methods: We conducted a secondary analysis of data from a randomized controlled trial of a caregiving intervention for preterm infants born less than 33 weeks postmenstrual age. Plasma was collected with a clinically indicated laboratory draw by neonatal intensive care unit nurses and analyzed by multiplex assay for cytokines, chemokines, and growth factors. Neurobehavior was assessed by research nurses at the time of discharge from the neonatal intensive care unit using the motor development and vigor and alertness/orientation clusters from the Neurobehavioral Assessment of the Preterm Infant. Neurodevelopment was assessed at 6 months corrected age by the developmental specialist in the hospital's neonatal follow-up clinic using the Bayley Scales of Infant Development, Third Edition. We used linear regressions to estimate the effect of cytokine levels on neurodevelopment and allowed the effects to differ by infant gender and race. Results: In a sample of 62 preterm infants with discharge neurobehavioral assessments and a sample of 40 preterm infants with 6-month neurodevelopmental assessments, we found inconsistent associations between single-time point inflammatory measures and neurobehavior or neurodevelopment in analyses of the total sample. However, regressions with interactions revealed effects for multiple inflammatory measures on early neurobehavior and neurodevelopment that differed by infant gender and race. Discussion: Although early single-time point measures of inflammation may be insufficient to predict neurodevelopment for all preterm infants, the effect of inflammation appears to differ by infant gender and race. These demographic factors may be important considerations for future studies of inflammation and neurodevelopment as well was the development of future interventions to optimize outcomes.

Research paper thumbnail of Gloving and Touch Practices of Neonatal Nurses

Journal of Perinatal & Neonatal Nursing, 2022

Supplemental Digital Content is Available in the Text. Positive tactile experiences in the newbor... more Supplemental Digital Content is Available in the Text. Positive tactile experiences in the newborn period are critical to normal sensory development. Universal gloving in the neonatal intensive care unit has become a controversial issue in neonatal nursing practice. Intended to prevent infection among neonatal patients, universal gloving also hinders the provision of human touch. The purpose of this survey study was to (1) describe gloving policies in neonatal intensive care units, and (2) describe the gloving and touch practices of neonatal nurses and identify associations between these practices and demographic characteristics. The investigators developed a 19-question, anonymous survey. The survey link was distributed through the National Association of Neonatal Nurses' social media and newsletter. Of the 137 responses, only 22.1% of nurses reported unit policy requiring universal gloving. While nurses reported some ambiguity about gloving policies, surveyed nurses commonly used gloves when performing general care activities. Institutional gloving policies varied in this geographically diverse sample, but routine, bare-handed touch was an uncommon practice among neonatal nurses. Research evidence is needed to guide nursing practice and inform policy decisions regarding glove use in the neonatal intensive care unit.

Research paper thumbnail of Measures of Stress Exposure for Hospitalized Preterm Infants

Nursing Research, 2020

Background Extended hospitalization in neonatal intensive care units subjects preterm infants to ... more Background Extended hospitalization in neonatal intensive care units subjects preterm infants to multiple stress exposures that affect long-term cognitive functioning, motor development, and stress reactivity. Measurement of stress exposure is challenging with multiple measures of stress exposure in use, including counts of skin-breaking or invasive procedures or counts of noxious sensory exposures. Objectives The purpose of this analysis was to compare measures of stress exposure commonly used by researchers and to determine the predictive validity of these measures for early neurobehavior. We accomplished this objective through the following specific aims: (a) describe the stress exposures of preterm infants in the first 2 weeks of life, (b) determine the correlations among measures of stress exposure, and (c) compare the predictive validity of measures of stress exposure for early neurobehavior. Methods Very preterm infants born between 28 and 31 weeks postmenstrual age were enro...

Research paper thumbnail of Behavioral Observation of Infants With Life-Threatening or Life-Limiting Illness in the Neonatal Intensive Care Unit

Nursing Research, 2020

Background: Infants in the neonatal intensive care unit experience aversive stimuli that cause pa... more Background: Infants in the neonatal intensive care unit experience aversive stimuli that cause pain and distress. Maintaining adequate relief from pain and distress is challenging because of infants' varying ages and stages of development and their nonverbal status. Thus, pain and distress must be interpreted by a healthcare provider or other proxy from their own observations or perceptions. There is no standard research or clinical measure for pain and distress in infants. Objective: The purpose of this analysis was to evaluate the use of the COMFORT Behavior (COMFORT-B) Scale as a measure of pain and distress in infants diagnosed with life-threatening or life-limiting illnesses in the neonatal intensive care unit in comparison with the nurse-documented Neonatal Pain, Agitation and Sedation Scale; the infants' Technology Dependence Scale; and the mothers' report of total perceived symptom scores. Methods: Infants diagnosed with life-threatening or life-limiting illnesses and hospitalized in a Level IV neonatal intensive care unit in the Midwestern United States and their parents were included. Measurement of pain and distress in infants was collected weekly from enrollment through 12 weeks or until discharge, whichever occurred first. Observations for the COMFORT-B Scale were conducted before and after standard caregiving activities. Pearson r correlations were used to compare means between pain and distress, technology dependence, and mothers' total perceived symptom scores over time. Results: Data from 78 infants (46 male and 32 female infants) of ages 23-41 weeks of gestation at birth were analyzed. No correlations were found among the COMFORT-B Scale; the Neonatal Pain, Agitation and Sedation Scale; and mothers' total perceived symptom scores. Moderate correlations were found among the Technology Dependence Scale; mothers' total perceived symptom scores; and the Neonatal Pain, Agitation and Sedation Scale. Discussion: Performing COMFORT-B observations can be challenging, and it is unclear whether the information obtained from the COMFORT-B Scale added to the assessment of the infant's pain and distress that is typically recorded in the health record or from parents. Further evaluation is needed to determine if it is more reliable to collect the Neonatal Pain, Agitation and Sedation Scale scores rather than conduct observations using the COMFORT-B Scale in studies of infants with life-threatening and life-limiting illnesses in the neonatal intensive care unit.

Research paper thumbnail of Association of Nurse Workload With Missed Nursing Care in the Neonatal Intensive Care Unit

JAMA pediatrics, Jan 12, 2018

Quality improvement initiatives demonstrate the contribution of reliable nursing care to gains in... more Quality improvement initiatives demonstrate the contribution of reliable nursing care to gains in clinical and safety outcomes in neonatal intensive care units (NICUs); when core care is missed, outcomes can worsen. To evaluate the association of NICU nurse workload with missed nursing care. A prospective design was used to evaluate associations between shift-level workload of individual nurses and missed care for assigned infants from March 1, 2013, through January 31, 2014, at a 52-bed level IV NICU in a Midwestern academic medical center. A convenience sample of registered nurses who provided direct patient care and completed unit orientation were enrolled. Nurses reported care during each shift for individual infants whose clinical data were extracted from the electronic health record. Data were analyzed from January 1, 2015, through August 13, 2018. Workload was assessed each shift with objective measures (infant-to-nurse staffing ratio and infant acuity scores) and a subjectiv...

Research paper thumbnail of Patterned feeding experience for preterm infants: study protocol for a randomized controlled trial

Trials, 2015

Background: Neurobehavioral disabilities occur in 5-15 % of preterm infants with an estimated 50-... more Background: Neurobehavioral disabilities occur in 5-15 % of preterm infants with an estimated 50-70 % of very low birth weight preterm infants experiencing later dysfunction, including cognitive, behavioral, and social delays that often persist into adulthood. Factors implicated in poor neurobehavioral and developmental outcomes are hospitalization in the neonatal intensive care unit (NICU) and inconsistent caregiving patterns. Although much underlying brain damage occurs in utero or shortly after birth, neuroprotective strategies can stop lesions from progressing, particularly when these strategies are used during the most sensitive periods of neural plasticity occurring months before term age. The purpose of this randomized trial is to test the effect of a patterned feeding experience on preterm infants' neurobehavioral organization and development, cognitive function, and clinical outcomes. Methods: This trial uses an experimental, longitudinal, 2-group design with 120 preterm infants. Infants are enrolled within the first week of life and randomized to an experimental group receiving a patterned feeding experience from the first gavage feeding through discharge or to a control group receiving usual feeding care experience. The intervention involves a continuity of tactile experiences associated with feeding to train and build neuronal networks supportive of normal infant feeding experience. Primary outcomes are neurobehavioral organization as measured by Neurobehavioral Assessment of the Preterm Infant at 3 time points: the transition to oral feedings, NICU discharge, and 2 months corrected age. Secondary aims are cognitive function measured using the Bayley Scales of Infant and Toddler Development, Third Edition at 6 months corrected age, neurobehavioral development (sucking organization, feeding performance, and heart rate variability), and clinical outcomes (length of NICU stay and time to full oral feeding). The potential effects of demographic and biobehavioral factors (perinatal events and conditions of maternal or fetal/ newborn origin and immunologic and genetic biomarkers) on the outcome variables will also be considered. Discussion: Theoretically, the intervention provided at a critical time in neurologic system development and associated with a recurring event (feeding) should enhance neural connections that may be important for later development, particularly language and other cognitive and neurobehavioral organization skills. Trial registration: NCT01577615 11 April 2012.

Research paper thumbnail of Perinatal stress, fatigue, depressive symptoms, and immune modulation in late pregnancy and one month postpartum

TheScientificWorldJournal, 2014

Stress and fatigue are common complaints of pregnant and postpartum women as is depression. These... more Stress and fatigue are common complaints of pregnant and postpartum women as is depression. These symptoms may be related to immunomodulation. However, few studies have examined these relationships. The aim of this study was to examine the relationships among stress, fatigue, depression, and cytokines as markers of immune modulation in prenatal and postpartum women. Women completed questionnaires and gave blood samples during late pregnancy and again at 4-6 weeks postpartum. Blood was analyzed for cytokines as measures of immune modulation. Stress, fatigue, and depression were experienced at moderately high levels, with higher levels of fatigue and depression in the postpartum but higher stress in the prenatal period. Levels of several cytokines were increased in the postpartum over the prenatal period. Stress and depression were related in the prenatal period and stress, depression, and fatigue were related in the postpartum. While various cytokines were related to each other in bo...

Research paper thumbnail of Measuring maternal responsiveness

The ABNF journal : official journal of the Association of Black Nursing Faculty in Higher Education, Inc, 2007

The purpose of this study was to review current research studies examining maternal responsivenes... more The purpose of this study was to review current research studies examining maternal responsiveness to locate self-report instruments, and to identify variables in these self-report instruments used to describe maternal responsiveness. The electronic databases, Medline, PsychLit, SocLit, and Cinahl were searched with the following key words: maternal responsiveness, maternal sensitivity, maternal attachment, maternal response, and responsiveness. Articles were obtained, assessed, and agreed upon for their usefulness to the study by the researcher and research assistant. Criteria included: articles must include key word, maternal responsiveness, in the title or a self-report instrument measuring maternal responsiveness. Fifty-two eligible studies were identified from the literature, read by two reviewers and both reviewers confirmed its applicability. All included studies were summarized in tabular form. References with the key words in the title were extracted from the literature to ...

Research paper thumbnail of A research protocol for testing relationships between nurse workload, missed nursing care and neonatal outcomes: the neonatal nursing care quality study

Journal of Advanced Nursing, 2014

AimWe describe an innovative research protocol to test the role of missed nursing care as a media... more AimWe describe an innovative research protocol to test the role of missed nursing care as a mediator of the association between nurse workload and patient outcomes in the neonatal intensive care unit.BackgroundIncreases in nurses' workloads are associated with adverse patient outcomes in neonatal intensive care settings. Missed nursing care is a frequently hypothesized explanation for the association between workload and outcomes. Few studies to date have tested missed care as a variable that mediates the workload–outcomes relationship.DesignWe use a longitudinal, observational study design.MethodsWe will recruit approximately 125 nurses (80% of target population) providing direct patient care in one neonatal intensive care unit. Four, 6‐week data collection cycles occur over 1 year. At the end of every shift, nurses report on their workloads and the frequency with which specific patient care activities were missed for each infant cared for during the shift. Infant‐specific nurs...

Research paper thumbnail of A descriptive study of nurse‐reported missed care in neonatal intensive care units

Journal of Advanced Nursing, 2014

AimsThe aims of this study are to describe: (1) the frequency of nurse‐reported missed care in ne... more AimsThe aims of this study are to describe: (1) the frequency of nurse‐reported missed care in neonatal intensive care units; and (2) nurses’ reports of factors contributing to missed care on their last shift worked.BackgroundMissed nursing care, or necessary care that is not delivered, is increasingly cited as a contributor to adverse patient outcomes. Previous studies highlight the frequency of missed nursing care in adult settings; the occurrence of missed nursing care in neonatal intensive care units is unknown.DesignA descriptive analysis of neonatal nurses’ self‐reports of missed care using data collected through a cross‐sectional web‐based survey.MethodsA random sample of certified neonatal intensive care nurses in seven states was invited to participate in the survey in April 2012. Data were collected from nurses who provide direct patient care in a neonatal intensive care unit (n = 230). Descriptive statistics constituted the primary analytic approach.ResultsNurses reported...

Research paper thumbnail of Parental Experience Learning to Feed Their Preterm Infants

Advances in Neonatal Care, 2014

Purpose-Although extensive research has been conducted on preterm infant oral feeding, few invest... more Purpose-Although extensive research has been conducted on preterm infant oral feeding, few investigations have examined parents' experiences learning to orally feed their preterm infant while in the neonatal intensive care unit (NICU). As such, the aim of this study was to explore parental learning experiences to gain a better understanding of the process parents' use in learning to feed their preterm infant. Subjects-Parents included in the investigation were18 years of age or older with a medically stable preterm infant that was less than 36 weeks gestational age at birth, free of congenital malformations, and feeding orally. Design-This investigation used hermeneutic phenomenology to explore the depth and richness of parental experience with the process of learning to orally feed their preterm infant. Methods-Participants were recruited from a university affiliated women's hospital with a Level III NICU. Purposive sampling was used to ensure that all participants were familiar with the experience of interest. Data collection consisted of personal interviews conducted in a private consultation room located within the NICU. In instances where both the infant's mother and father chose to participate, the interviews were conducted separately on the same day. Main Outcome measures-Twelve mothers and eight fathers participated in semi-structured interviews. For eight mothers and six fathers, this was their first child. This was the first preterm infant for all participants. From the parental experience three themes were identified: an emotional experience; learn as you go; and it's technical. Principal Results-Parents noted that feeding encompassed both positive as well as negative emotions, that learning was a process that nurses played an instrumental role in, and that feeding a preterm infant could be very technical requiring extra skills for feeding success.

Research paper thumbnail of Caring for a Preterm Infant at Home

Journal of Perinatal & Neonatal Nursing, 2013

The purpose of this phenomenological study was to examine the experiences of mothers of preterm i... more The purpose of this phenomenological study was to examine the experiences of mothers of preterm infants during the first 6 months at home following discharge from a neonatal intensive care unit (NICU). A purposeful sample of 8 mothers was gathered and interviews were conducted over a 4-month period. Each interview was audio recorded and took place in the study participant's home or another place of her choosing. Interviews were transcribed verbatim and analyzed independently with themes being identified and organized for each participant. From these analyses, the themes of fear, exhaustion, determination, and thankfulness were identified as being common to all study participants and became the basis for developing the essence of the phenomenon. The essence of this experience for these mothers was their resolve to do whatever was necessary to ensure the best possible outcomes for their infants. The data gathered from these personal interviews will serve to further inform our understanding of this important time from the perspective of those who experienced it, as well as aid in the design of interventions to address the specific needs of these mothers prior to NICU discharge.