<p>Human infants share common biological and developmental needs in the postnatal period that are optimally met during intimate contact with their mother or primary caregiver. In the case of infants hospitalised in tertiary-level neonatal intensive care units (NICUs), there is a departure from instinctual caregiving and nurturing found in the mother-infant pair, due in part, to a model of care which supports maternal-infant separation. This can lead to suboptimal physiological responses, altered neurobiology and life-long negative health effects. The social construction of neonatal care currently positions it within the paradigm of biomedical science. Where family-centred, developmental care frameworks have been integrated, and Kangaroo Mother Care (KMC) has been embedded into caregiving routines, enhanced patient, whānau/family, staff and organisational outcomes have been found. This study is underpinned by the importance of KMC for the enhancement of infant and whānau/families’ health and developmental outcomes. Despite its classification as an evidence-based practice, and recommendations by the World Health Organisation for its use in all healthcare settings, KMC is inconsistently applied. The highly complex and contextual nature of the environments where medically-dependent babies are cared for is acknowledged. There is a need for health services to explore innovative research approaches, through a social science lens, to assist in the implementation of KMC. This thesis illustrates one such approach. The purpose of this study was to explore and activate improvement of the KMC programme within one NICU in Aotearoa New Zealand using Participatory Action Research (PAR). The research was theoretically informed by Als’ developmental biology and care theories, D’Agata’s Infant Medical Trauma model, and the Foucauldian concept of power/knowledge through a critical feminist lens. A participatory approach was chosen in the hope that transformation of KMC practice would be achieved and embedded within this NICU. In addition, I intended to contribute to the emerging body of evidence calling for the collaboration of all community members toward enhanced quality of KMC. Multiple methods were used to capture data relating to the NICU’s KMC programme through audit, observation and interview of key stakeholders. Project planning included the conventions of PAR generally applied to research using this methodology. Three iterative cycles of exploration, implementation and evaluation of the KMC programme were envisaged within this setting. Active participation with multiple NICU stakeholders was planned for, forming the basis of action-based change and improvement of KMC. However, the three-cycle process was not achieved within the time limitations of my research, with field work finishing at the conclusion of the first exploratory cycle. This thesis describes the unfolding processes of PAR, as well as the inclusion of a secondary discourse analysis and parental perspectives from local and global literature. Key findings showed inconsistently documented KMC and the near-absence of KMC practice for a significant group of babies. Whilst the benefit of KMC was embedded in the understanding of participants, this knowledge did not translate to practice. There was an unrealistic optimism about the functioning of KMC by most of the stakeholders. In addition, participants expressed ambiguity about their programme, contributing to and influenced by suboptimal KMC education and training. A pathway to improvement of their KMC programme was lacking, and the lines of responsibility for it were unclear. This factor undoubtedly contributed to the difficulties of implementing a full PAR project. Whilst parental, staff and organisational factors were found to influence KMC implementation, arguably the greatest effect on the intervention were the power relations inherent within the normative technocratic, biomedical paradigm. Power relations constituting what was considered authoritative knowledge, and who was authorised to speak, impacted on the participatory nature of the research itself. This resulted in the research not proceeding past the first PAR exploratory cycle through to rounds of implementation and evaluation. This thesis describes participatory inquiry into one KMC programme in the high-income NICU setting, through the lenses of multiple participants within the context of Aotearoa New Zealand. These were not previously known. It also provides an example of how Foucauldian- and feminist-informed PAR methodology may be used within the NICU setting for inquiry into KMC, an intervention positioned outside of the normative biomedical framework.</p>
Implementation and effectiveness of continuous kangaroo mother care: a participatory action research protocol
