Proceedings of the 2018 Design of Medical Devices Conference DMD2018 April 9-12, 2018, Minneapolis, MN, USA DMD2018-6915 Downloaded from http://asmedigitalcollection.asme.org/BIOMED/proceedings-pdf/DMD2018/40789/V001T10A009/2788243/v001t10a009-dmd2018-6915.pdf by guest on 26 September 2021 CONTEXTUAL DESIGN THEORY APPLIED TO WEARABLES THAT FACILITATE KANGAROO CARE BY INTERVIEWING MOTHERS OF HOSPITALIZED INFANTS Abigail R. Clarke-Sather Kelly Cobb Department of Mechanical & Industrial Eng. Department of Fashion & Apparel Studies University of Minnesota Duluth University of Delaware Duluth, Minnesota, USA Newark, Delaware, USA Catherine Maloney Hannah Young Department of Mechanical & Industrial Eng. Department of Fashion & Apparel Studies University of Minnesota Duluth University of Delaware Duluth, Minnesota, USA Newark, Delaware, USA BACKGROUND KC is an early caregiver-infant behavior that improves When considering how to design medical devices infant motor, cognitive, and social-emotional development considering the needs of the patient and hospital staff may including for infants at risk. KC improves emotional seem sufficient. Hospitalized infants are patients who cannot regulation, alertness, and neurodevelopmental outcomes [1]. speak or advocate for their needs; the parents and the hospital KC provides a calm and soothing environment that reduces staff caring for infant patients have different roles that together stress, positions the infant to encourage motor and mental are integral to an infant’s recovery. Figure 1 shows how development, and allows infants to sleep more readily and mothers, nurses, and infants form a system of care to promote deeply [2], [3]. KC is shown to encourage breastfeeding infant patient healing. In particular caregiver behaviors such through increasing mothers’ milk production, rates of as kangaroo care (KC), are dependent upon the involvement of breastfeeding exclusivity, and breastfeeding duration [3]. KC family. KC, defined as bare skin-to-skin contact between an has been shown to improve sleep and reaction to pain during infant and an adult caregiver, is usually done chest-to-chest. procedures [4]. The design of wearables for the caregivers holding the infant Specifically care in a neonatal intensive care unit (NICU) patient can make KC easier and be part of wearable medical requires many resources—nursing, equipment, financial, and device design that improves infant patient outcomes. emotional [5]. Parents and infants in NICUs experience stress and may have difficulty bonding [2]. KC improves parent child bonding and reduces parental stress [2], [3]. KC best practices include: being held skin to skin by Infant mothers as soon as possible after birth; babies be held skin to Patient skin by mothers continuously, and in the case of intermittent holding that babies be held for at least one hour [6]. Medically stable infants can benefit from the start of KC within 24 hours of birth, resulting in statistically significantly shorter hospital Nurse stays [7]. Mother Significance: The age at which premature infants are Education (Hospital (Family) treated and survive has become younger in the U.S. over the Child advocacy Staff) past decades [8]. The gestational age of premature babies that Communication are treated varies between hospitals; a study of 24 hospitals between 2006 and 2011 showed that of infants born at 22 Figure 1: Infant patient care team and roles 1 Copyright © 2018 ASME weeks gestational age receiving active treatment 23.1% survived and 9% survived with minimal health setbacks [9]. The rates of infant prematurity in the U.S. has decreased from 12.8% to 9.8% over the past decade [10], [11]. However, 7.9 per 1000 babies born in 2012 received care in NICUs [12] and nearly 4 million babies were born in the U.S. in 2010 [13]; thus, it can be presumed that hundreds of thousands of mothers Downloaded from http://asmedigitalcollection.asme.org/BIOMED/proceedings-pdf/DMD2018/40789/V001T10A009/2788243/v001t10a009-dmd2018-6915.pdf by guest on 26 September 2021 in the U.S. cared for infants who have received care in NICUs in the U.S. since 2010. Existing KC assists such as garments for mothers (e.g. NuRoo, Hudlo baby, milk & baby, Precious Image) and preterm baby carriers available commercially (e.g. K’tan, Uchi) do not work well for use in the NICU. Commercially available garments do not easily allow the infant to enter KC due to the tubes that connect the infant to medical devices. Discreet skin exposure for KC, breastfeeding and pumping breastmilk is difficult for mothers with commercially available garments including easy garment donning and doffing in a confined space. Figure 3: Demographics of interviewed mothers The aim of this project is to understand mothers’ perspectives on doing KC in hospitals. Hospitals are unique Only the KC results are discussed in this paper. 12 of the environments where KC barriers may be different than in other interviewers were conducted in English, 1 of the interviews environments. These preliminary findings explore limitations was conducted in Spanish. Mothers were recruited via mother to these important early caregiver behaviors in the hospital. support groups either online or in person. These interviews were transcribed and then coded using grounded theory METHODS methodology [16]. Interview data was transcribed, systematically coded for themes with descriptive statistical Infant hospital care involves a complex system of actors analysis performed in MS Excel. who work to improve a child’s health outcomes. Contextual Design theory stresses the importance of gathering feedback from end users while working. Incorporating feedback from RESULTS the workers’ user preferences into the design of systems is Ten of the 13 mothers interviewed had cared for their considered essential for success [14]. One of the approaches children in the NICU. Their children ranged from 24 weeks to for studying and incorporating user feedback into design is full term (defined as 36 weeks 6 days) gestational age (Fig. 2). through interviews of end users [15]. The mother-baby-nurse Seven mothers mentioned where their children were system of medical care was studied from the perspective of hospitalized representing 5 different hospitals’ NICUs and 6 mothers to investigate what impedes and supports mothers’ different hospitals. Figure 3 shows demographic information work of KC, breastfeeding, and pumping breastmilk in the of the interviewed mothers. care of hospitalized infants. The themes that arose in the interviews were how: nurses, 13 mothers from the U.S. East Coast were interviewed in medical condition, and privacy influenced KC. How KC person (n=12) or via skype (n=1) from March to August 2017 influenced mother-child bonding and breastfeeding emerged. about their experiences with KC, breastfeeding, and pumping Each mother was asked about clothing she used for KC. breastmilk in the NICU or hospital by 6 different interviewers. Nurses: Four mothers described NICU nurses as gatekeepers to kangaroo care in terms of nurse attitudes toward KC, hospital schedule, and mothers’ and children’s medical conditions. Regarding nurse attitudes, a mother noted “some of the nurses are more inclined to push you to do the kangaroo care than other nurses are.” Nurses affected when, how, where, and if KC was done. Two mothers mentioned that they needed to conform to the hospital schedule in terms of hours or activities. One mother described the hospital schedule as 4-hour blocks. Another mother mentioned the repetition of activities KC, pump breastmilk, wait. The schedule that NICU nurses and other hospital staff kept determined mothers’ ability to do KC. One mother commented on the different medical condition of her child and attitudes of nurses in different Figure 2: Infant demographics (w=weeks, d= days) hospitals that helped make KC possible; “I was not able to 2 Copyright © 2018 ASME hold him at all at [Hospital 1], I think he was just too unstable, but I mean at [Hospital 2] they were amazing, they would do anything it took to get me to hold him.” Hospitals likely reinforce different attitudes among nurses towards KC. One mother mentioned that it was difficult to argue with the NICU nurses. Two mothers mentioned that getting to hold their child felt like a fight. As one mother commented on KC Downloaded from http://asmedigitalcollection.asme.org/BIOMED/proceedings-pdf/DMD2018/40789/V001T10A009/2788243/v001t10a009-dmd2018-6915.pdf by guest on 26 September 2021 in the hospital “some nurses were more comfortable with … me being a little more independent, some nurses … didn’t want me to … take him out. … it just depended on them [the nurses] which was kind of annoying.” Some mothers viewed the hospital and/or its staff as hindering their ability to do KC. Figure 4: Number holds per day and hold duration (hours) Medical condition: Infant medical condition made KC total KC time increased as their child’s health condition challenging. Two mothers mentioned their children’s medical improved. condition specifically as a barrier to KC. Three mothers Privacy: Mothers’ opinions about privacy during KC mentioned the following that their infants were connected to differed. Two mothers expressed a lack of concern about as making KC more difficult: exposing their skin, yet an awareness that others, including • nasogastric tube down the nose (for feeding); nurses, might be uncomfortable with their nakedness might • umbilical catheter; differ from their own. One mother who had cared for multiple • pulse oxygenation monitor on the toes; children in the NICU expressed this sentiment in this way “at • wires and cords; and this point I was like I don’t care, I am going to do what I want • alarms that sounded when cords detached. and you can wait or come talk to me while I am doing this.” The equipment connected to their children or the alarms These mothers, despite their own comfort with exposing their that sounded when that equipment detached made it difficult skin, noticed others’ (including nurses’) lack of comfort with physically and emotionally to do KC.