DISSERTATION PROTOCOL

1 Name of the Candidate Mrs.Trupti M Palkar B/204 Sai vikas C H S, Saibaba Nagar, Mira Road, District-Thane, Maharastra.

2 Name of the Institution HINA College of Nursing

Yelahanka New Town,

Bangalore-560064

3 Course of the institution M.Sc. Nursing

(Child health nursing)

th 4 Date of admission to the 30 JUNE 2011

course 5 Title of the topic :

“A study to assess the effectiveness of structured teaching programme on

knowledge regarding effect of noise on physical,physiological and

behavioural responses of low birth weight babies among staff nurses in

Neonatal Intensive Care Unit of selected hospitals at Bangalore”. 6.0 BRIEF RESUME OF THE INTENDED WORK INTRODUCTION

1 “SILENCE IS THE MOTHER OF TRUTH’’ -BENJAMIN DISRAELI

Noise is ubiquitous in our environment. High intensities of noise have been associated with numerous health effects in adults, including noise-induced hearing loss and high blood pressure. The intent of this statement is to provide pediatricians and others with information on the potential health effects of noise on the fetus and newborn. The information presented here supports a number of recommendations for both pediatric practice and government policy. 1

Low birth weight new borns spend many months in Neonatal Intensive Care Units before they are well enough to be discharged home. Premature infants are exposed to a variety of stressful stimuli in the NICU,painful and invasive procedures, prolonged ventilation, continuous bright lighting and loud noises.Small preterm infants are particularly sensitive to traumatic NICU stimuli due to severe illness,chronic pain and immature neurologic development.2

Neonatal intensive care unit (NICU) are constantly exposed to ambient noise that often exceeds recommended levels. There is a growing concern that such noise puts preterm infants at high risk for adverse health effects. This review looks at the effects of NICU noise on the cardiovascular, respiratory, auditory and nervous systems. Loud transient noise has negative short-term effects on the cardiovascular and respiratory systems of preterm infants, although direct evidence linking noise to neonatal pathology is still unclear. Further controlled trials with larger sample sizes are needed to determine the effects of more extensive exposure to NICU noise on early brain maturation and long-term developmental outcomes.3

2 Low birth weight babies in the NICU are often exposed to continuous loud noise despite research documenting the presence and damaging effects of noise on the infant's development. Excessive auditory stimulation creates negative physiologic responses such as apnea and fluctuations in heart rate, blood pressure, and oxygen saturation. Preterm infants exposed to prolonged excessive noise are also at increased risk for hearing loss, abnormal brain and sensory development, and speech and language problems.4

Reducing noise levels in the NICU can improve the physiologic stability of sick neonates and therefore enlarge the potential for infant brain development. Recommendations include covering incubators with blankets, removing noisy equipment from the incubator environment, implementing a quiet hour, educating staff to raise awareness, and encouraging staff to limit conversation near infants.4

6.1 NEED FOR STUDY

3 Neonatal intensive care unit (NICU) are constantly exposed to ambient noise that often exceeds recommended levels. There is a growing concern that such noise puts low birth weight infants at high risk for adverse health effects. This review looks at the effects of NICU noise on the cardiovascular, respiratory, auditory and nervous systems.5

Noice levels in the NICU have potentially adverse effects on infant physiologic stability and future neuro development.Loud transient noice has been shown to cause immediate physiological changes such as increased heart rate, blood pressure and respiratory rate, and decreased oxygen saturation. Such changes increase the likelihood of subsequent apnoea and bradycardia episodes. The existing evidence regarding the effects of noise on NICU patients does not yet allow us to make definitive conclusions.6

Many of the studies in this area of research are limited due to lack of randomization, small sample sizes and large variations in the gestational ages of the infants and the experimental techniques used. In addition, the chronological ages of the infants at testing varied significantly, and confounding medical problems were not adequately accounted for in most of the studies. There is also a lack of recent studies in this field, with the majority evidence coming from research performed decades ago. Further research and more rigorous clinical investigations are needed to directly link noise exposure to pathology and to examine its effects on early brain development and long-term developmental outcomes. Maintaining safe noise levels within the NICU will enhance the capacity of critically ill infants to cope with the unexpected transition from the protective uterine environment to the overwhelming world of the NICU.6

4 Most NICU's are not adhering to the sound level recommendations as advised by the AAP. The excessive noise levels are placing infants at risk for both short-term and long-term negative health outcomes. NICU staff, hospital administrators, and visitors need to educated on the deleterious effects of increased sound levels. Paying special attention to detail when designing and altering the NICU environment will also help to eliminate sources of increased noise. Eliminating excessive noise in the NICU environment is essential in promoting positive health outcomes for preterm and term infants.7

Premature infants in the neonatal intensive-care unit often exposed to continuous loud noise. This excess auditory stimulation creates negative physiological responses, such as increased heart and respiratory rates and decreased oxygen saturation. Modifying the neonatal intensive-care unit to reduce noise levels provides an environment more conducive to maturation and recovery from illness. This article reviews the literature addressing the pathophysiology and physiological changes of the premature infant in response to stress and discusses practice interventions for decreasing noise levels in the neonatal intensive-care unit. These interventions include installing sound absorbing materials and minimizing conversations of the staff.8

5 Several recent studies have found exceedingly high noise levels in the neonatal intensive care unit (NICU) and in incubators. The purpose of this study was to perform a detailed noise assessment in a Canadian NICU. A noise level meter was used to evaluate ambient noise levels in three rooms of the NICU and to compare those levels with measurements taken inside an occupied incubator. Mean hourly noise levels measured inside the incubator (61 dB) were significantly higher than those measured outside (55 dB). Ambient noise levels were also significantly higher in rooms where staff activity was greatest (59dB). In addition, peak noise levels in excess of 120 dB were found. These findings are consistent with those of previous studies and suggest that noise levels in the NICU are excessive. Furthermore, staff activity is a significant contributor. The suggestion that noise in the NICU is detrimental to both auditory and central nervous system development is discussed and intervention strategies are recommended.9

The investigator felt the need of the study during the clinical posting, she observed that staff nurses were unawaire about the effect of noise in low birth weight babies and because of their,they were unable to give comprehensive care to the low birth weight babies. So the researcher felt that awaireness should be created among staff nurses to regarding effect of noise on physical, physiological and behavioral responses of low birth weight babies in NICU inorder to deliver quality care to low birth weight babies for the fast recovery.

6.2. REVIEW OF LITERATURE.

Review of literature is an important step in which an exclusive extensive search on the concerned topic is done to gather relevant information.

This chapter deals with selected studies, which are related to objective the proposed study to “A study to assess the effectiveness of structured teaching programme on knowledge regarding effect of noise on physical,physiological and behavioural responses of low birth weight babies among staff nurses in NICU of selected hospitals at Bangalore”.

6 The review of literature involves the identification, selection, critical analysis and written description of existing information or a topic.

The study reveals that the source of noise in level III NICU in Beijing region,Noise measurements were performed in level III NICU of three hospitals(A, B and C) in Beijing region by dosimeter (B&K 2231, Denmark), during loudhours and quiet hours. Among the three hospitals, the average noise of was (62.60 +/- 2.33) dB during the loud time, and (55.80 +/- 2.61) dB during the quiet time, with a difference of 7 dB (P < 0.05). There was a significant decrease of 3 dB during nursing time with the averages of A hospital (62.0 +/- 2.4) dB, B hospital (64.90 +/- 1.06) dB(P < 0.01), respectively, and 2.5 - 3.0 dB during treatment time with the averages of A hospital (60.7 +/- 2.2) dB, B hospital (63.30 +/- 1.19) dB (P <0.05), separately. After educating the staff in hospital A, there was a significant decrease of 4.7 dB from (61.70 +/- 2.12) dB to (56.90 +/- 2.49) dB in the loud time (P < 0.01), no significant difference during quiet time from (55.0 +/- 1.7) dB to (53.90 +/- 0.88) dB (P > 0.05). There was a significant decrease of 10 dB (P < 0.01) between the averages of inside of incubator (58.60 +/- 3.43) dB and outside of incubator (67.10 +/- 1.87) dB; After installing foam material inside incubator with the average of (56.20 +/- 1.83) dB, there was a significant decrease of 2.8 dB (P < 0.01); covering sheet (in front and back) with the averages of (57.00 +/- 1.47) dB and (55.3 +/- 1.3) dB, respectively, and single or double blanket outside incubator (in the front and the back) noise value(54.50 +/- 1.33) dB, (54.10 +/- 1.15) dB and (54.70 +/- 0.63) dB and (54.10 +/-1.14) dB, separately, there was a decrease of 1 - 4 dB (P < 0.05 and P < 0.01). Staff behavior and the acoustical characteristics of the facility determine the level of noise; herein to staff behavior is the main cause.10

The study reveals that Preterm infants in the neonatal intensive care unit (NICU) are constantly exposed to ambient noise that often exceeds recommended levels. There is a growing concern that such noise puts preterm infants at high risk for adverse health effects. This review looks at the effects of NICU noise on the cardiovascular,respiratory, auditory and nervous systems. Loud transient noise has

7 negative short-term effects on the cardiovascular and respiratory systems of preterm infants, although direct evidence linking noise to neonatal pathology is still unclear. Further controlled trials with larger sample sizes are needed to determine the effects of more extensive exposure to NICU noise on early brain maturation and long-term developmental outcomes.11

8 The study reveals that High noise levels (>70 dB) in the neonatal intensive care unit (NICU) are common in some primary hospitals. This study aimed to investigate the noise in the NICU on auditory system and intelligence development in premature infants. One hundred premature infants with respiratory distress syndrome who needed mechanical ventilation therapy were randomly divided into observation and control groups according to the use of earmuffs. The duration of mechanical ventilation therapy lasted for 2 to 15 days in the two groups. After weaning from mechanical ventilator, the auditory brainstem response, cranial B-ultrasonography, and the intelligence development assessment were performed.The percentage of total (23% vs 47%) and mild hearing loss (15% vs 35%) in the observation group was significantly lower than that in the control group(p<0.05) 2 to 3 days after weaning from mechanical ventilator. The incidence of periventricular hemorrhage intraventricular hemorrhage (PVH-IVH) or periventricular leukomalacia (PVL) in the observation group was significantly lower than that in the control group (21% vs 42%; p<0.05). The noise in the NICU can result in mild hearing loss and retardation of intelligence development and increase the incidence of PVH-IVH and PVL in premature infants. The use of earmuff may reduce the adverse events.12

The study reveals that Premature infants in the NICU are often exposed to continuous loud noise despite research documenting the presence and damaging effects of noise on the preterm infant's development. Excessive auditory stimulation creates negative physiologic responses such as apnea and fluctuations in heart rate, blood pressure, and oxygen saturation. Preterm infants exposed to prolonged excessive noise are also at increased risk for hearing loss, abnormal brain and sensory development, and speech and language problems. Reducing noise levels in the NICU can improve the physiologic stability of sick neonates and therefore enlarge the potential for infant brain development. Recommendations include covering incubators with blankets, removing noisy equipment from the incubator environment, implementing a quiet hour, educating staff to raise awareness, and encouraging staff to limit conversation near infants.13

9 The study reveals that noise and light levels for extremely low birth weight newborns throughout their stay in the NICU,evaluate factors influencing noise and light levels, and determine whether exposures meet recommendations from the American Academy of Pediatrics.Sound and light were measured inside the beds of extremely low birth weight newborns (n = 22) from birth to discharge. Measurements were recorded for 20 consecutive hours weekly from birth until 36 weeks' postmenstrual age,biweekly until 40 weeks, and every 4 weeks thereafter. Result is Age- related changes in respiratory support and bed type explained the weekly increase of 0.22 dB in sound level and 3.67 lux in light level. A typical extremely low birth weight neonate was exposed to noise levels averaging 56.44 dB(A) and light levels averaging 70.56 lux during their stay from 26 to 42 weeks' postmenstrual age in the NICU. Noise levels were rarely within American Academy of Pediatrics recommendations (5.51% of the time),whereas light levels almost always met recommendations (99.37% of the time).14

10 The study reveals that Noise in neonatal intensive care units (NICUs) may impede growth and development for extremely low-birth-weight (ELBW, < 1000 g) newborns. Sound levels inside the incubator, heart rate (HR), and arterial blood pressure recordings were simultaneously collected for eight ELBW neonates for 15 minutes during the first week of life. Cross-correlation functions were calculated for NICU noise, HR, and mean arterial blood pressure (MABP) recordings for each subject. ELBW neonates' HR and MABP were significantly correlated ( R = 0.16 at 2-second lag time), with stronger correlation apparent for higher-birth- weight ELBW newborns (0.22 versus 0.10). Lower-birth-weight newborns responded to increased noise with HR acceleration from 45 to 130 seconds after noise events, and higher-birth-weight infants initially responded with an HR deceleration at 25 to 60 seconds, then HR acceleration ~175 seconds after noise increased. MABP was not as strongly correlated with NICU sound levels, although some correlation coefficients were slightly outside the 95% confidence interval. NICU noise influenced newborns'HR, indicating that these infants hear and respond to NICU sounds.15

The study reveals that Hospital noise levels were measured for four consecutive days every two hours throughout the day in a neonatal intensive care unit (NICU), a normal nursery room and inside infant incubators when the latter were associated with different types of life- support equipment. There was a difference in the noise level between normal nursery and NICU, whereas a considerable increase of noise was recorded when the infant received supplemental oxygen, was under ventilator or when an air compressor was in operation. High noise levels were equally the same both in a.m. and p.m. hours in the NICU. As many high risk infants spend a long time in a NICU, there is an urgent need for further evaluation of noise levels and their effect on the outcome of infants.16

11 The study reveals that aspects of the neonatal intensive care unit's physical and care giving environment may contribute to the development of subtle developmental problems in infants with significant exposure. The effects of auditory and visual stimuli on infants are areas that have been studied. A review of relevant research studies is provided, along with recommendations for nursing practice.17

This study evaluates the exposure of newborn babies in neonatal intensive care units (NICU) to noise which can cause hearing lesions directly (acoustic trauma) as well as indirectly (hypoxia). Moreover, noise can have an aggravating effect when combined with other potentially harmful factors in the NICU, such as ototoxic medication or stress due to other external stimuli, such as excessively bright light, lack of a day/night rhythm or pain. Findings revealed that the influence of ambient noise is fairly irrelevant. Background noise and its variations concerned with activities in the department never exceeded the limits considered potentially harmful to adults (DRC), whereas the impulsive noise generated by staff on the cribs or on the plexiglas tops was considerable and potentially harmful. These findings demonstrate that it is feasible and relatively easy to control noise in the NICU and significantly reduce the impulsive noise component by training staff to be more careful and avoid any unnecessary jolting and rough handling on and near the cribs.18

6.3 STATEMENT OF THE PROBLEM:

“A study to assess the effectiveness of structured teaching programme on knowledge regarding effect of noise on physical, physiological and behavioural responses of low birth weight babies among staff nurses in Neonatal Intensive Care Unit of selected hospitals at Bangalore”.

6.4 OBJECTIVES OF STUDY: 1. To assess the pre test knowledge regarding effect of noise on physical, physiological and behavioural responses of low birth weight babies among

12 staff nurses in NICU. 2. To evaluate the effectiveness of Structured Teaching Programme on knowledge regarding effect of noise on physical, physiological and behavioural responses of low birth weight babies among staff nurses in NICU. 3. To find out the association between post test knowledge score with their selected demographic variables

6.5 RESEARCH HYPOTHESIS:

 H1: There is a significant difference in the pre test and post test knowledge of staff nurses regarding effect of noise on physical, physiological and behavioural responses of low birth weight babies in NICU.

 H2: There is a significant association between post test knowledge score with their selected demographic variables. 6.6 OPERATIONAL DEFINITIONS: Assess:It refers to the statistical measurement of knowledge of staff nurses regarding effect of noise on physical, physiological and behavioural responses of low birth weight babies in NICU elicited through structured knowledge questionnaire. Effectiveness:It refers to significant gain in knowledge as determined by pre and post test knowledge scores. Structured Teaching Programme:It refers to organized group teaching programme for 45minutes in lecture cum discussion method to impart knowledge on staff nurses regarding effect of noise on physical, physiological and behavioural responses of low birth weight babies in NICU. Knowledge: It refers to the response given by the respondents to the questionnaire. Noise: It refers to the sound of any kind. Physical: It refers to external changes. Physiological: It refers to internal changes of body. Behavioural: It refers to react in specific way to stimulate.In this study it means babies response.

13 Low birth weight babies:It refers to abnormally low weight less than 2.5kg. NICU: It refers to a place where care to be taken for the newborn baby.

6.7 ASSUMPTIONS:

 Staff nurses will have some knowledge regarding effect of noise on physical, physiological and behavioural responses of low birth weight babies in NICU.  Structured teaching programme will enhance the knowledge of staff nurses on effect of noise on physical, physiological and behavioural responses of low birth weight babies in NICU.  The knowledge varies from one Individual to another.

6.8 DELIMITATIONS: This study is delimited to,  The present settings of the selected hospitals.  Staff nurses who all are working in hospitals. 7. MATERIALS AND METHOD: 7.1 SOURCE OF DATA: The source of data will be from the staff nurses in selected hospitals at Bangalore. 7.2 METHOD OF DATA COLLECTION: The data will be collected by investigator herself by using structure closed ended questionnaires. 7.2.1i.RESEARCH DESIGN: One group Pre-test and Post-test. ii.RESEARCH APPROACH: Quasi experimental method 7.2.2 SETTING: This study will be conducted among staff nurses in selected hospitals at Bangalore. 7.2.3 POPULATION: The population of the present study will be selected among staff nurses in

14 selected hospitals at Bangalore. 7.2.4 SAMPLING TECHNIQUE: Purposive sampling technique will be used to select the sample for the study. 7.2.5 SAMPLE SIZE: The approximate sample size will be 50 staff nurses. 7.2.6 SELECTION CRITERIA INCLUSION CRITERIA: Staff nurses,  Who are willing to participate in the study.  Who are available during the data collection period. EXCLUSION CRITERIA: Staff nurses,  Who have already attended classess regarding effect of noise on physical, physiological and behavioural responses of low birth weight babies in NICU.  Who cannot speak and understand Kannada or English. 7.2.7 DATA COLLECTION TOOL: Structured questionnaire scheduled consist of following sessions which is constructed in English language Section 1-Demographic Performa A structured questionnaire for collecting demographic data of staff nurses in selected hospitals. It consist of selected demographic variables like age,qalification,year of experience,licnical area of work, training of NICU. Section11-Structured questionnaire on knowledge A structured questionnaire used to assess the level of knowledge among staff nurses regarding effect of noise on physical, physiological and behavioural responses of low birth weight babies in NICU. 7.2.8 PERIOD OF DATA COLLECTION: The data collection period is 6 weeks. 7.2.9 METHOD OF DATA COLLECTION Formal permission will be obtained from the concerned authority of selected hospitals,to conduct the study.Informed concent will be taken from the samples and the samples will be selected on the basis of selection criteria. 15 PHASE 1-Pre test will be conducted to assess the knowledge of the staff nurses on effect of noise on physical, physiological and behavioural responses of low birth weight babies in NICU using a self- administered questionnaire. PHASE 2-Structured teaching programme on effect of noise on physical, physiological and behavioural responses of low birth weight babies in NICU will be conducted to the staff nurses. PHASE 3-After one week post-test will be administered to assess the level of knowledge on effect of noise on physical, physiological and behavioural responses of low birth weight babies in NICU to the same subjects with the help of same questionnaire. 7.2.10DATA ANALYSIS METHODS: The collected data will be organized,tabulated and analysed by using descriptive statistics and inferential statistics.  Descriptivestatistics-mean,median,mode,standarddeviation,percentage distribution will be used to assess the knowledge of staff nurses on effect of noise on physical, physiological and behavioural responses of low birth weight babies in NICU.  Inferential statistics-Chi square test will be used to associate the knowledge of staff nurses with selected demographic variables.  projected outcome-After the pre-test,the investigator administers structured teaching programme to the staff nurses on effect of noise on physical, physiological and behavioural responses of low birth weight babies in NICU which will help them to initiate a positive step in rendering effective care to such childrens.. 7.3Does the study required any investigation or intervention to be conducted on patient or other humans or animals? If so, please describe briefly. -Yes- 7.4 Has ethical clearance been obtained from your institution in case of 7.3?

16 Required ethical clearance and other permission will be taken from concerned authorities and written consent will be taken from the sample before collection of data. 8. BIBILIOGRAPHY

1. http://aappolicy.aappublications.org/cgi/content/full/pediatrics

2. Al Williams-2008-books.google.com

3. http://fn.bmj.com/content/96/4/f305.abstract

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6. http://brighamandwomens.org/Research/depts/newborn medicine/researches/lahav/documents/watchman and lahav-2010

7. Larson L, (2010); “Can you hear me now?”;Ky Nurse;58(3),10.

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9. Kent W D,Tan A K et al,(2002); “Exessive noise level in the NICU”;J Otolaryngol;31(6),355-60.

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12.Li W J,Jiang H B et al,(2009); “Effect of noise on the auditory system and the intelligence development of premature infants treated in the neonatal intensive care unit”;Zhongguo Dang Dai Er Ke Za Zhi;11(12),976-79.

17 13.Brown G,(2009); “NICU infant and the pre term infant”;Neonatal network;28(3),165-73.

14.Lasky R E,Williams A L,(2009) “Noise and light exposure for extremely low birth weight newborns during their stay in the NICU”;Paediatrics;123(2),540-46.

15.Williams A L,Sanderson M et al,(2009); “Intensive care noise and mean arterial blood pressure in extremely low birth weight neonates”; Am J Perinatol;26(5),323- 29.

16.Anagnostakis D,Petmezakis J et al,(1980); “Noise pollution in neonatal unit”;Acta paediatric scand;69(6),771-73.

17.Lotas M J,(1992); “Effects of sound and light in the NICU environment on the low birth weight infants;NAACOGS Clin Issue perinat womens health health nursing;3(1),34-44.

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9. SIGNATURE OF THE CANDIDATE:

10. REMARKS OF THE GUIDE: 11. NAME AND DESIGNATION OF THE GUIDE:

11.2. SIGNATURE

18 OF THE GUIDE: 11.3: HEAD OF THE DEPARTMENT:

11.4. SIGNATURE:

12. REMARKS OF THE CHAIRMAN AND PRINCIPAL:

13.SIGNATURE :

19