Experiences of Indonesian nurses in improving preterm oral feeding readiness in special care units: A qualitative descriptive study

Study Design

A qualitative descriptive study design (Doyle et al., 2020; Kim et al., 2017) was employed to explore the phenomena of nurses in more depth regarding their behavior, feelings, and experiences to answer what, how, and why the phenomena of increasing preterm oral feeding readiness admitted to the intensive care unit occurred. The research report adhered to the guidelines provided by the consolidated criteria for reporting qualitative research (COREQ) (Tong et al., 2007).

Samples/Participants

The study was conducted in a specialized referral hospital for high-risk infants in Central Java, Indonesia, which has implemented developmental care and the Family Centered Care (FCC) approach in the care of preterm infants. The hospital’s treatment room was divided into the High Care Unit (HCU) for level II preterm infants and the Neonatal Intensive Care Unit (NICU) for level III preterm infants. The research participants included nurses in the neonatal special intensive care unit. The sampling technique used was purposive sampling, aimed at gaining access to observations and conducting interviews with nurses to obtain rich data for interpretation (Holloway & Galvin, 2017). This approach also aimed to capture variations in demographic data among nurses based on their education level and the level of the neonatal special intensive care room (Haenssgen, 2019). Participant selection was criterion-based, and the inclusion criteria for the study consisted of nurses who met the following conditions: 1) possessed a minimum education level of an associate degree in nursing; 2) had at least two years of work experience; and 3) had completed training in neonatal-specific intensive care rooms for a minimum of 3 months.

Data Collection

Data were collected from January to March 2023. A semi-structured, in-depth interview method was chosen, and it was conducted by the first researcher, a pediatric nurse with experience caring for preterm infants in the special care unit. The first researcher also received training in preterm infant care management and developmental care. The purpose of using the semi-structured in-depth interview method was to explore the nurses’ perspective, including their inner thoughts and perspectives on who, where, and what factors are involved in improving preterm oral feeding readiness. These interviews were conducted face-to-face in the HCU and NICU nursing rooms. There were no other participants present in the interview room to allow for the capture of both verbal and nonverbal responses during the interview (Doyle et al., 2020).

Prior to commencing data collection, the researchers conducted a pilot interview to develop questions that aligned with the research objectives and to refine their communication skills. The results of the pilot interviews were then discussed with the supervisors (researchers 2, 3, and 4) to create interview guidelines and establish effective communication methods for conducting in-depth interviews. The interview guideline contained initial questions to facilitate the development of further questions during the interview process. The questions included: 1) What do you think about preterm oral feeding readiness? 2) What is the nurse’s experience in improving preterm oral feeding readiness? 3) What is the nursing care process to improve preterm oral feeding readiness? 4) Are there other opinions that you would like to convey in increasing preterm oral feeding readiness?

Data collection used a voice recorder, an Android smartphone for recording interviews, writing instruments, a laptop, and field note sheets. Stationery and field notes were used to document participants’ responses to questions, nonverbal communication, and keywords and terms used by the participants. Interview meetings with participants were conducted twice in the hospital discussion room. The first meeting aimed to establish a trusting relationship, provide informed consent, and agree upon the interview schedule. The second meeting involved the actual interviews. The interview typically lasted 30 to 60 minutes, and no repeat interviews were conducted. The researcher recorded verbal and nonverbal responses during the interview process in field notes. The saturation of research data was discussed with the research team (researchers 2, 3, and 4), and data were deemed saturated in the tenth participant when no new codes emerged (a total of 122 codes generated).

Data Analysis

Thematic analysis, as outlined by Kiger and Varpio (2020), was employed to analyze relevant themes to address research questions related to improving preterm oral feeding readiness through nursing care. This analysis facilitated a comprehensive exploration of nurses’ experiences, behaviors, and perspectives concerning preterm oral feeding readiness. The steps involved in thematic analysis consisted of 1) Recognizing data by reading the entire interview transcript, making notes or memos, and identifying keywords; 2) Initial coding of data, which the data were coded briefly to provide meaningful descriptions; 3) Identifying subthemes and themes by examining the list of codes and their relationships to organize codes into broader subthemes and themes, describing their significant meanings, 4) Reviewing themes, 5) Defining and naming themes, and 6) Writing the results.

Additionally, the researcher utilized the framework proposed by Abfalter et al. (2021) for the translation process, which consists of seven steps: 1) Why: The translation aimed to establish scientific value and academic interest in society for publication in international journals, 2) When: Translation occurs during the final stages of data analysis and dissemination of findings, 3) What: Research results, including meaningful statements, coding, subthemes, themes, and publication manuscripts were translated. Transcripts were not translated due to the extensive amount of text; 4) Who: The first researcher prepared the draft for translation from Indonesian to English, and an experienced external translator carried out the translation; 5) How: The translation followed a technical or forward translation approach from Indonesian to English. The first researcher, who conducted the interview data collection, prepared the results of data analysis and publication manuscripts for translation by external translators. The translated results were then validated by the second, third, and fourth researchers through comparison with the Indonesian version; 6) Where: The translation took place in the socio-geographical environment of the language source where the research data were collected to preserve the original meaning and contextual information based on the subcultural and social identities of the research participants, 7) By What Means: External translators with experience in translating qualitative health research results were employed for the translation process. Bilingual dictionaries and not IT applications were used as auxiliary tools.

Trustworthiness

The trustworthiness in this study included objectivity, dependability, credibility, transferability, and applicability (Hays & McKibben, 2021). Objectivity implies that the research was carried out in an unbiased and rational manner, involving peer debriefing and discussions with supervisors who were experts in neonatology, nursing, and nutrition. Dependability or reliability, which assesses data consistency over time, was ensured through the inquiry audit method. This method involved the participation of a supervisor in developing keywords, coding, subthemes, and themes. Credibility was maintained by verifying the truth value of the data through member checking. Feedback on the final themes was provided to all participants through email or other designated contacts. Additionally, data triangulation was performed by examining nursing records, including assessments, nursing diagnoses, planning, implementation, and evaluations. Transferability, which assesses the ability to generalize research results to the broader population, was facilitated by presenting research findings to allow readers to draw conclusions about the identified themes. Applicability involves ensuring that the research results are valid and transferable. This was achieved by preparing manuscripts that provide comprehensive information about the research findings to benefit readers.

Ethical Considerations

This research underwent ethical scrutiny and received approval from the ethical review board of Universitas Indonesia, with approval number KET-285/UN2.F12.D1.2.1/PPM.00.02/2022 on 28 December 2022. This study adhered to ethical principles by demonstrating respect for participants and allowing them the autonomy and self-determination to refuse or participate in the study. Informed consent was obtained from participants after the researcher thoroughly explained the study’s purpose, potential benefits, and procedures. Additionally, the researcher emphasized the importance of confidentiality and anonymity, safeguarding participants’ identities and data, including notes, recordings, and interview transcripts. The researchers also upheld the principle of beneficence by explaining how the research could advance scientific knowledge and took measures to minimize any potential risks, such as discomfort, during the interview process, thereby ensuring non-maleficence. The selection of participants was based on predetermined inclusion and exclusion criteria, promoting justice in the research process. Furthermore, the ethical principle of preventing exploitation was applied, ensuring that actions or activities did not unduly take advantage of participants (Holloway & Galvin, 2017).

Theme 1: Comprehensive and Holistic Nursing Assessment

The assessment of preterm infants’ readiness for oral feeding begins with an initial evaluation upon their admission to the intensive care unit. During this initial assessment, nurses consider various factors, including the infants’ general condition, gestational age, weight, breathing patterns, and primary complaints. For instance, preterm infants with favorable general conditions and stable breathing patterns are candidates for oral feeding. The assessment process is elucidated by the statements of the first and seventh participants:

“…the initial assessment will consider gestational age, weight, and the reason for admission…” (P1)

“…If the infant’s breathing pattern is compromised, we cannot use bottle feeding…” (P7)

Subsequently, an ongoing assessment is conducted, with the fourth participant emphasizing the importance of assessing the gastrointestinal tract’s function in preterm infants. This assessment involves examining factors such as gastric residue, intestinal sounds, the presence or absence of vomiting, and abdominal distension. Notably, gastric residue is evaluated by draining the feeding tube 1-2 hours before scheduled feedings rather than aspirating gastric fluid. This precautionary measure aims to minimize the risk of stress ulcers and necrotizing enterocolitis (NEC) in preterm infants.

“…if the residue is brown, it is the same as the yellow residue; if the stomach still shows optimal wall elasticity, we can feed the infant as long as the intestinal noise is positive…” (P4)

“…we do not use aspiration because it can cause stress ulcers and NEC…” (P4)

Data obtained from the assessment of gastrointestinal tract function serve as a basis for nurse evaluations, which include assessing the gastrointestinal tract’s absorption capacity, determining appropriate nutrient intake, and devising intervention plans for preterm infants. When breast milk is well-absorbed, nurses may increase the amount of breastfeeding or initiate sucking reflex stimulation. Conversely, if breast milk absorption is inadequate, the feeding interval may be extended. The third and fourth participants provide insights into this aspect:

“…usually, we look at the intake first. If the intake is good, preterm infants are given 10 ml of breast milk twice per shift. If this is good, it means it has good absorption. The infant can digest. When the infant shows this condition, we usually train the suction reflex…” (P3)

“…If an infant is given 3 cc and the residue during the day is recorded at 2 cc, it means there is a residue. With this condition, we extend the provision of nutrition from 3 hours to 4 to 5 hours…” (P4)

Additionally, the first participant highlights the significance of assessing the preterm infants’ ability to maintain physiological stability. Hemodynamic status, oxygenation, vital signs, and the type of oxygen therapy are assessed. If hemodynamic status and oxygenation are within normal limits, nurses proceed with oral feeding training, which may involve direct feeding, bottle feeding, or oral feeding during Kangaroo Mother Care (KMC):

“…for the nurse’s role in feeding, whether it’s bottle or oral, we check the infant first. If he is in good condition, with stable hemodynamics and breathing patterns, we then train the mother for oral feeding with KMC…” (P1)

It is essential to consider the type of oxygen therapy administered to preterm infants. Infants still reliant on invasive oxygen therapy, such as ventilators, should not undergo oral feeding. Enteral or parenteral feeding methods are alternatives for these infants. Only when preterm infants have transitioned to non-invasive oxygen therapy, such as nasal cannulas, can they participate in oral feeding exercises, as explained by the third participant:

“…If the infant’s condition improves, we prepare the infant for KMC, which is usually in the NICU here. The infant must be weaned from the ventilator. Maybe he is extubated if an endotracheal tube is attached or at least a Non-Invasive Ventilator (NIV) mask is attached…” (P3)

Moreover, the second and third participants introduce additional assessment steps for evaluating preterm infants’ oral-motor skills, focusing on their sucking and swallowing reflexes. This assessment involves observing feeding cues, assessing the strength and weakness of sucking and swallowing reflexes, and implementing assessment methods such as dripping breast milk through a syringe into the infants’ oral area or providing non-nutritive sucking using gauze soaked in glucose:

“…we check the suction reflex, sometimes we drip the infant’s mouth with breast milk…” (P2)

“…we then train the mother to use gauze or sterile cloths soaked in glucose, and then we observe the suction reflex…” (P3)

Theme 2: Challenging and Complex Nursing Issues

The data collected during the assessment phase served as the basis for identifying nursing problems in preterm infants experiencing oral feeding difficulties. Nurses followed nursing diagnosis formulation standards based on the Indonesian Nursing Diagnosis Standards (SDKI) and Indonesian Nursing Output Standards (SLKI). They analyzed the assessment data, comparing it with the definitions, causes, major data, and minor data specified in nursing standards. The tenth participant elaborated on this process:

“…first, let’s delve into the diagnosis-making process. We scrutinize the causes one by one, ensuring they align with SDKI and SLKI because our hospital adheres to them. We ensure that major symptoms and signs constitute about 80%, and then we establish the actual diagnosis, incorporating minor signs that bolster our diagnosis…” (P10)

The eighth participant pointed out that the most prevalent nursing problems encountered during the transition to oral feeding in preterm infants were related to nutritional deficits and the associated risk. These problems were linked to data indicating suboptimal nutrient absorption function, manifesting as red gastric residue, vomiting, abdominal distention, and weight loss:

“…nursing diagnoses can also manifest as a risk of nutritional deficit. Supporting data might include weight loss, the presence of feeding residue, vomiting, and ongoing abdominal distention” (P8)

Nutritional intake issues also stemmed from the oral-motor capabilities of preterm infants. The fifth participant described how nurses established a nursing diagnosis of ineffective breastfeeding, primarily based on the weak sucking and swallowing reflexes of preterm infants:

“…so, in specific cases, we might diagnose it as ineffective breastfeeding…” (P5)

Additionally, oral feeding readiness in preterm infants had an impact on their families. According to the eighth participant, nursing problems related to the ineffectiveness of lactation management could be identified in families with preterm infants. These issues included aspects such as the type of nutrition to be provided, breastfeeding methods, breast milk storage, the quantity of breastfeeding, and the timing of administration. This aligns with the statements of the seventh and eighth participants:

“…as for the family, the problem might pertain to lactation management…” (P8)

“…regarding milk feeding, whether it’s breast milk, expressed milk, or direct feeding, and how to store breast milk. If it’s formula milk, select the appropriate type of milk. These decisions fall to the family…” (P7)

Furthermore, nurses formulated nursing issues related to fluid intake. These problems emerged due to insufficient nutrient intake in preterm infants during the transitional phase of oral feeding and included issues such as hypovolemia:

“…if there’s a significant impact, reduced feeding naturally leads to reduced intake…” (P7)

Respiratory function in preterm infants also gave rise to nursing problems. This was linked to the immaturity of the respiratory system, resulting in disruptions to breathing patterns during oral feeding. These nursing issues were characterized by unstable hemodynamic status during oral feeding, including problems related to ineffective breathing patterns and airway clearance. Both types of nursing problems contributed to impaired oral feeding readiness in preterm infants, as described by the third participant:

“…in general, nursing problems in preterm infants with low birth weight often revolve around breathing patterns, particularly in cases where endotracheal tubes are employed for an extended period, airway hygiene frequently poses challenges…” (P3)

Theme 3: The Need for Nutritional Management Skills

Following the identification of nursing problems, nurses proceeded to implement interventions to enhance preterm oral feeding readiness. These interventions included various aspects, including nutritional management. The second participant described a practice where nurses addressed gastric residue issues. If the gastric residue appeared red, nurses either satisfied the preterm infant or performed gastric lavage:

“…if the infant is admitted with an orogastric tube in place, we check the residue. If possible, we may need to perform gastric lavage…” (P2)

The tenth participant highlighted the importance of assessing the color of stomach residues in preterm infants. When the residue was yellow, gradual feeding was continued. In specific cases, such as surgical instances involving preterm infants with gastroschisis, green residue prompted gradual feeding with dextrose or breast milk nutrition:

“…if the residue is only yellow, we can continue with small feedings. However, certain cases, particularly surgical cases like gastroschisis, may require fasting. But when the residue is green, the surgeon may recommend gradual feeding to stimulate the intestines, typically involving small increments. While formula milk is not advisable, dextrose or breast milk may be considered…” (P9)

Once the development of the gastrointestinal tract absorption function of preterm infants improved, nurses introduced trophic feeding. This gradual feeding approach, typically starting with 1-2 ml of breast milk per shift, aimed to stimulate the gastrointestinal tract’s function. It was aligned with the physiological characteristics of the infant’s small stomach, with the quantity of breastfeeding adjusted according to the infant’s weight. Participants provided insights into this practice:

“…we gradually introduce trophic feeding, starting at 1 cc for a few days, then progressing to 3 cc, and later 5 cc. We avoid immediately providing large amounts of feeding…” (P1)

“…Depending on the residue, if it appears clear and the stomach feels supple, we provide feeding as needed, in small increments. Infants have small stomachs, similar in size to peanut seeds. Trophic feeding involves gradual increases, with up to 1 cc, 2 cc, or 3 cc based on the infant’s requirements and weight…” (P4)

Furthermore, in the transition period of oral feeding for preterm infants, nurses actively stimulated the development of sucking and swallowing reflexes. They achieved this through non-nutritive sucking interventions, such as moistening gauze with dextrose and stimulating the infant’s mouth area to elicit sucking and swallowing responses. Once preterm infants had these reflexes, oral feeding exercises were initiated:

“…for stimulating the sucking reflex, we often employ gauze moistened with dextrose to elicit the reflex. We place it in the infant’s mouth, where we can hear the sucking sound. If the sucking reflex is present, we proceed with feeding, taking into account the infant’s ability to suck and swallow. Sometimes, an infant may have the sucking reflex but not the swallowing reflex, or vice versa…” (P4)

The fifth participant noted that oral feeding was initiated as soon as possible, provided there were no contraindications. Typically, oral feeding commenced when preterm infants reached a postmenstrual age of 34-35 weeks. The participant shared:

“…as long as it’s deemed appropriate for the infant to feed, we don’t delay the process. If there’s breast milk available, we use that for feeding…” (P5)

“…typically, oral feeding is initiated at a corrected age of around thirty-four to thirty-five weeks. If attempted earlier than this, the infant’s sucking reflex may be quite weak, and there’s a risk that the infant could choke, as breast milk may still flow too easily…” (P5)

However, the fourth participant emphasized that the initiation of oral feeding didn’t necessarily depend on reaching a specific corrected age, such as 34 or 36 weeks. Instead, it hinged on the infant demonstrating a proficient sucking reflex. This approach allowed nurses to start oral feeding for preterm infants once they had this capability:

“…it doesn’t have to be precisely at 34 or 36 weeks of gestation; that’s not a strict requirement. Essentially, if the infant demonstrates a strong sucking reflex, we begin feeding. We don’t fixate on specific gestational ages, like 32 or 33 weeks…” (P4)

Nurses evaluated the progress of preterm infants’ oral feeding readiness throughout the oral feeding period. Evaluations performed during each shift included assessments of gastric residues, gastrointestinal bleeding, abdominal distention, and intestinal noise. To maintain continuity of documentation, nurses recorded the oral feeding progress of preterm infants in electronic medical records:

“…typically, with each shift, we assess the suction, feeding, and gastric residue reflexes. During these assessments, we monitor for any signs of distension or gastrointestinal bleeding. If everything appears favorable, we continue to observe, provided there are no contraindications. We reevaluate, checking for good bowel sounds, absence of residue, and non-distended conditions before proceeding with intake…” (P3)

Additionally, the second and tenth participants mentioned conducting further evaluations by examining anthropometry and nutritional status, particularly weight gain, when there was an improvement in the sucking reflex:

“…we manage the nutrition and then conduct body weight measurements and assess fluid balance…” (P2)

“…anthropometry is crucial. We measure weight to determine if it aligns with our expectations. We also pay attention to the status of the sucking reflex, whether it’s improving or deteriorating…” (P10)

Theme 4: The Necessity of Collaborative Support

The participants engaged in collaborations with other healthcare professionals to enhance the readiness of preterm infants for oral feeding, including pediatricians. This collaboration involved considerations regarding the timing and method of oral feeding. Additionally, there was a collaboration in administering medication therapy to minimize gastrointestinal bleeding, such as vitamin K and erythromycin.

“……..he also advised to give oral intake gradually…” (P2)

“… medical action, for example, gastric bleeding can be given vitamin K or erythromycin…” (P8)

In cases where some preterm infants struggled with the transition to oral feeding, as indicated by suboptimal weight gain, the sixth participant emphasized the importance of nurses collaborating further with the metabolic nutrition division. Recommendations made to the metabolic nutrition division included providing enteral nutrition for maintenance.

“… usually, the infants are fed three to four times per shift by being trained by drip via an orogastric tube, and then we train them to feed via bottle, too. If the infant’s weight is not optimal or his oral nutritional performance is not good, a metabolic nutrition specialist will replace it with formula milk. We then perform maintenance, so for 8 hours, for example, we feed the infant per hour, and then we evaluate whether there’s residue or not. We can feed for 4 hours straight or 5 hours depending on the body weight…” (P6)

The first participant mentioned another form of collaboration involving working with the medical rehabilitation department to train the sucking and swallowing reflexes of preterm infants. These exercises, known as oro-motor training, aim to enhance preterm infants’ oral feeding readiness.

“…so far, preterm infants need good suction reflex though it is difficult. We train preterm infants to have it. We often work with the Medical Rehabilitation department to do oro-motor training…” (P1)

The participants also highlighted the importance of collaborating and partnering with families to enhance the oral feeding readiness of preterm infants. They motivated families to optimize breastfeeding in the intensive care room, as it is beneficial for the development of preterm infants’ gastrointestinal tracts. Nurses provided education on breastfeeding techniques and Kangaroo Mother Care (KMC) to support the oral feeding of preterm infants.

“…we provide education when patients are still being treated here in the hope that when the mother’s milk comes out, we recommend breast milk only. We also educate on how to express breast milk that can be stored in breast milk bags…” (P2)

“…we provide education to mothers on how to express breast milk…” (P5)

Strengths and Limitations of the Study

This research has comprehensively explored nurses’ experiences in enhancing preterm oral feeding readiness in both Level III and Level II intensive care units. This exploration was conducted through in-depth interviews and the examination of nursing record documentation. However, a limitation of this study was the absence of further investigation from multidisciplinary perspectives, including doctors, physiotherapists, and speech therapists. Therefore, it is recommended that future research should explore preterm oral feeding readiness from a multidisciplinary standpoint.

Implications of the Study

This research has significant implications for nursing, particularly for neonatology nurses caring for preterm infants in special care units. These nurses should focus on developing specialized skills to enhance preterm oral feeding readiness. These essential skills include conducting comprehensive assessments and evaluating the physiological functions of preterm infants’ body systems, such as the neuromuscular and gastrointestinal tract. Additionally, nurses should excel in behavioral assessments, keenly observing preterm infants’ oral feeding readiness cues. Addressing nursing challenges related to preterm infants’ oral feeding abilities, such as coordinating sucking-swallowing-breathing and managing the psychological impact on parents, particularly maternal stress, is paramount.

Furthermore, nurses must possess proficiency in nutritional management, including the skills required for analyzing gastric residues in preterm infants, delivering trophic feeding, and stimulating development to boost oral feeding readiness. Innovative nursing interventions, such as gently introducing breast milk to the oral area of preterm infants to provide a positive oral experience, are essential. Collaborative skills are equally vital for neonatology nurses. They should cultivate cooperative relationships with other healthcare professionals, including doctors, physiotherapists, and speech therapists. Moreover, nurses should engage in effective partnerships with families to implement nursing interventions to enhance preterm oral feeding readiness through education and KMC practices.