The development of a neonatal communication intervention tool Esedra Strasheim

The development of a neonatal communication intervention tool Esedra Strasheim

The development of a neonatal communication intervention tool

by

Esedra Strasheim

Submitted in the fulfilment of the requirements for the degree

M.Communication Pathology

(Speech-Language Pathology)

in the

Department of Communication Pathology

Faculty of Humanities

University of Pretoria

Supervisor: Prof B. Louw

Co-supervisor: Prof A. Kritzinger

November 2009

© U n i i v e r r s s i i t t y o f f P r r e t t o r r i i a

Abstract

Abstract

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Title: The development of a neonatal communication intervention tool

Researcher: Esedra Strasheim

Supervisors: Prof. B. Louw & Prof. A. Kritzinger

Department: Department of Communication Pathology

Degree: M.Communication Pathology

Comprehensive management in the neonatal nursery involves medical treatment of the infant, as well as developmental care and the provision of guidance, counselling and information to the family who are part of the decision-making process regarding the infant’s care. Neonatal communication intervention is of utmost importance in a country such as

South Africa, which has an increased prevalence of infants at risk for disabilities and where the majority of these infants live in poverty.

Speech-language therapists fulfil an important role in the neonatal nursery and are an integral part of the team involved with the high risk neonatal population. Local literature showed a dearth of information on the current service delivery and roles of speech-language therapists and audiologists in neonatal nurseries in the South African context. From an asset-based perspective it appears that the South African population receiving services in neonatal nurseries have unique characteristics. This provides speechlanguage therapists with ample opportunity to intervene, providing that intervention is well-timed in the neonatal nursery context.

The country-wide initiative to implement the evidence-based technique of kangaroo mother care indicates that speech-language therapists should recognise its importance and develop communication based materials and tools to complement this successful neonatal intervention. The aim of the research was to establish whether speech-language therapists have needs for assessment and intervention tools/materials in this context. The study

Abstract furthermore aimed to compile a locally relevant neonatal communication intervention instrument/tool for use by speech-language therapists in the neonatal nurseries of public hospitals in South Africa in order to propose a solution to address the shortage of tools in the public health context.

The study entailed descriptive, exploratory research. During Phase 1, a survey was received back from 39 speech-language therapists and two audiologists in six provinces. The data revealed that participants performed different roles in neonatal nurseries, which were determined by the environment, tools, materials and instrumentation available to them. Many participants were inexperienced, but were resourceful in their attempts to develop and adapt tools/materials. Participants expressed a need for culturally appropriate and user-friendly instruments for parent guidance and staff/team training on the topic of developmental care.

During Phase 2 a tool for parent guidance titled “Neonatal communication

intervention programme for parents” was compiled for use by speechlanguage therapists and justified by participants’ roles and needs as well as current early communication intervention (ECI) literature. The programme was piloted by three participants. Certain suggestions for enhancements of the programme were made such as providing a glossary of terms, adapting the programme’s language and terminology, and providing more illustrations.

The programme complied with the guiding principles for best practice in ECI

(ASHA, 2008) and can therefore contribute to neonatal care of high risk infants in South Africa. Speech-language therapists and audiologists must contribute to neonatal care of high risk infants to facilitate optimal health and development and to support their families.

Key words: Early communication intervention (ECI); kangaroo mother care

(KMC); neonatal communication intervention; developmental care; public health care context; neonatal intensive care unit (NICU); high risk infant.

Opsomming

Opsomming

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Titel: Die ontwikkeling van ‘n neonatale kommunikasie intervensie instrument

Navorser: Esedra Strasheim

Studieleiers: Prof. B. Louw & Prof. A. Kritzinger

Departement: Departement Kommunikasiepatologie

Graad: M.Kommunikasiepatologie

Omvattende intervensie in die neonatale sorgeenheid behels mediese behandeling van die neonaat, sowel as ontwikkelingstoepaslike sorg en die verskaffing van leiding, berading en inligting aan die gesin wat deel is van die besluitnemingsproses rakende die baba se sorg. Neonatale kommunikasie intervensie is van uiterste belang in Suid-Afrika aangesien daar ‘n hoër prevalensie van babas is wat ‘n risiko het vir ontwikkelingsafwykings en aangesien die meerderheid van hierdie babas in armoede leef.

Spraak-taalterapeute vervul ‘n belangrike rol in die neonatale sorgeenheid en is ‘n integrale deel van die span wat betrokke is by die hoërisiko neonatale populasie. Plaaslike literatuur dui op ‘n tekort aan inligting rakende die huidige dienslewering van die spraak-taalterapeut en oudioloog in neonatale sorgeenhede in die Suid-Afrikaanse konteks. Vanuit ‘n bate-benadering kom dit voor of die Suid-Afrikaanse populasie wat dienste in neonatale sorgeenhede ontvang, unieke eienskappe het. Dit bied genoegsame geleenthede aan spraak-taalterapeute om intervensie te verskaf, solank die behandeling betyds in die neonatale sorgeenheid konteks aanvang neem.

Daar is ‘n landswye inisiatief om die bewysgerigte tegniek van kangeroe moedersorg toe te pas. Spraak-taalterapeute moet dus die belang daarvan herken en kommunikasie gebasseerde terapiemateriaal ontwikkel om hierdie suksesvolle neonatale intervensie te komplementeer. Die navorsing se doel was om vas te stel hoe wyd spraak-taalterapeute en oudioloe ‘n behoefte aan evaluasie en intervensie instrumente en –materiaal in hierdie konteks het.

Die navorsing het verder ten doel gestel om ‘n relevante terapie instrument saam te stel vir spraak-taalterapeute in die neonatale sorgeenhede as ‘n

Opsomming moontlike oplossing vir die tekort aan relevante terapiemateriaal in die plaaslike publieke gesondheidsorgkonteks.

Die studie het beskrywende, eksplorerende navorsing behels. Gedurende

Fase 1 is ‘n vraelys terug ontvang van 39 spraak-taalterapeute en twee oudioloë in ses provinsies. Die data het aangedui dat deelnemers verskillende rolle in hierdie konteks vervul, wat beïnvloed was deur die omgewing, die instrumentasie en materiaal wat tot hulle beskikking was. Die meerderheid van die deelnemers was onervare, maar was vindingryk in hulle pogings om terapiemateriaal aan te pas en te ontwikkel. Deelnemers het ‘n behoefte vir kultureel toepaslike- en gebruikersvriendelike instrumente en materiaal uitgedruk met die oog op ouerleiding en personeel/span opleiding oor die onderwerp van ontwikkelingstoepaslike sorg.

Gedurende Fase 2 is ‘n terapie instrument naamlik “Neonatale kommunikasie

intervensie program vir ouers” saamgestel vir die gebruik in die neonatale sorgeenhede deur spraak-taalterapeute. Die samestelling van hierdie program is verantwoord deur die deelnemers se rolbeskrywing en behoeftebepaling van Fase 1, sowel as deur huidige vroeë kommunikasie intervensie (VKI) literatuur. Die program is deur drie deelnemers in ‘n loodsstudie geëvalueer. Voorstelle vir die verbetering van die program is verskaf, naamlik die byvoeging van ‘n terminologielys, aanpassing van die program se taalgebruik en terminologie en verskaffing van meer illustrasies.

Die program het ooreengestem met die beginsels vir beste praktyk in VKI

(ASHA, 2008) en kan daarom tot neonatale sorg van hoërisikobabas in Suid-

Afrika bydra. Spraak-taalterapeute en oudioloë moet bydra tot neonatale sorg van hoërisiko neonate om sodoende optimale gesondheidsorg en ontwikkeling te fasiliteer en gesinne te ondersteun.

Sleutelterme:

Vroeë kommunikasie intervensie (VKI); kangeroe moedersorg (KMS); neonatale kommunikasie intervensie; ontwikkelingstoepaslike sorg; publieke gesondheidsorg konteks; neonatale intensiewe sorgeenheid (NISE); hoërisikobaba.

CONTENTS

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CHAPTER 1

PERSPECTIVES ON THE ROLE OF THE SPEECH-LANGUAGE THERAPIST AND

AUDIOLOGIST IN THE NEONATAL NURSERY

1.1 INTRODUCTION………………………………………………………………………………………. 1

1.2 THE ROLE OF THE SPEECH-LANGUAGE THERAPIST AND AUDIOLOGIST IN

THE NICU………………………………………………………………………………………………….

1.3 ECI IN THE NEONATAL NURSERY IN THE SOUTH AFRICAN CONTEXT………

1.4 ENHANCING NEONATAL COMMUNICATION INTERVENTION SERVICES……… 10

1.5 CONCLUSION AND RATIONALE………………………………………………………………… 11

1.6 DESCRIPTION OF TERMINOLOGY……………………………………………………………… 12

2

5

1.7 CHAPTER OUTLINE…………………………………………………………………………………… 14

1.8 SUMMARY…………………………………………………………………………………………………. 15

CHAPTER 2

BEST PRACTICE IN NEONATAL CARE IN SOUTH AFRICA

2.1 INTRODUCTION………………………………………………………………………………………. 16

2.2 THEORETICAL UNDERPINNINGS FOR A NEONATAL COMMUNICATION

INTERVENTION TOOL……………………………………………………………………………….

2.2.1 Best practice in developmental care…………………………………………….

19

19

2.2.2 ECI service delivery in South Africa………………………………………………

2.2.3 The population requiring developmental care………………………………

2.2.4 The team involved in neonatal care services in public hospitals…

2.2.5 Programmes and services in neonatal care in South Africa………….

2.2.6 Neonatal communication intervention: The role of the speechlanguage therapist……………………………………………………………………….

39

47

24

32

36

2.2.7 Neonatal communication intervention tools in South Africa……….

CHAPTER 3

50

2.3 CONCLUSION…………………………………………………………………………………………… 56

2.4 SUMMARY………………………………………………………………………………………………… 57

METHODOLOGY

3.1 INTRODUCTION………………………………………………………………………………………. 58

3.2 AIMS………………………………………………………………………………………………………… 59

3.3 RESEARCH DESIGN…………………………………………………………………………………. 59

3.4 RESEARCH ETHICS…………………………………………………………………………………. 61

3.5 PHASE 1…….……………………………………………………………………………………………… 63

3.5.1 Objectives……………………………………………………………………………………… 63

3.5.2 Sample……………………………………………………………………………………………. 63

3.5.2.1 Population………………..….……………………………………………………. 63

3.5.2.2 Criteria for the selection of participants…………………………… 63

3.5.2.3 Selection procedures…………………………………………………………… 64

3.5.2.4 Description of the participants…………………………………………… 65

3.5.3 Materials…………………………………………………………………………………………. 73

3.5.3.1 Cover letter…………………………………………………………………………. 73

3.5.3.2 Self-designed questionnaire………………………………………………… 74

3.5.3.3 Pilot study…………………………………………………………………………… 81

3.5.4 Validity and reliability of the questionnaire…………………………………. 83

3.5.5 Data collection procedures……………………………………………………………. 84

3.5.6 Data analysis and statistical procedures………………………………………. 85

3.6 PHASE 2……………………………………………………………………………………………………. 87

3.6.1 Objectives.……………………………………………………………………………………… 87

3.6.2 Data collection procedures……………………………………………………………. 87

3.6.3 Trustworthiness issues…….……………………………………………………………. 88

3.7 CONCLUSION……………………………………………………………………………………………. 89

3.8 SUMMARY…………………………………………………………………………………………………. 89

CHAPTER 4

RESULTS AND DISCUSSION

4.1 INTRODUCTION…………………………………………………………………………………………. 91

4.2 RESULTS PHASE 1…….………………………………………………………………………………. 92

4.2.1 Objective 1: To describe the perceptions of speech-language therapists and audiologists providing ECI services in provincial hospitals regarding their roles in neonatal nurseries……….…………… 92

4.2.1.1 Screening and assessment of infants….……………..………………. 92

4.2.1.2 Intervention directed at the infant and parents/caregivers. 92

4.2.1.3 Intervention directed at staff and team members………….... 99

4.2.1.4 Audiologists’ perceptions of their roles in neonatal nurseries………………………………………………………………………………. 100

4.2.1.5 Participants’ perceptions of competence and work satisfaction………………………………………………………………………… 102

4.2.1.6 Improved future service delivery………………………………………. 110

4.2.2 Objective 2: To identify participants’ needs in terms of neonatal communication intervention instruments/tools…………………….……… 115

4.2.2.1 Assessment instruments or tools……….……………………………….. 115

4.2.2.2 Intervention tools/materials for use with parents/ caregivers……………………………………………………………………………. 118

4.2.2.3 Intervention tools/materials for use with staff/team members…………………………………………………………………………………

4.2.2.4 Audiologists’ needs in terms of instruments/tools for assessment and intervention…………………….……………………………

120

122

4.2.2.5 General perceptions regarding clinical instruments/tools…. 123

4.2.3 Conclusion of Phase 1……………………………………………………………………… 126

4.3 RESULTS OF PHASE 2…….……………………………………………………………………………. 127

4.3.1 Objective 3: To select and justify a specific need of the participants in terms of neonatal communication intervention instruments/tools in the public hospital context…………………………

4.3.1.1 Justification of the selection of a specific need: speechlanguage therapists’ needs and their roles….……………………

127

4.3.1.2 Justification of the selection of a specific need: current literature………………………………………………………………………………

127

130

4.3.2 Objective 4: To compile a preliminary instrument/tool based on the selection of one of the perceived needs of the participants…. 133

4.3.2.1 Aim of the tool……………………………………………………………………. 133

4.3.2.2 Considerations for the training of adult learners………….…… 133

4.3.2.3 Procedures followed in the compilation of the “Neonatal

135 communication intervention programme for parents”………………

4.3.2.4 Sequence and content of the “Neonatal communication intervention programme for parents”………………………………………… 137

4.3.2.5 Format of the “Neonatal communication intervention programme for parents”….…………………………………………………………. 142

4.3.3 Objective 5: To pre-test the “Neonatal communication intervention programme for parents”……………………………………………… 144

4.3.4 Conclusion of Phase 2.……………………………………………………………………………… 149

4.4 SUMMARY……………………………………………………………………………………………………. 150

CHAPTER 5

CONCLUSION AND RECOMMENDATIONS

5.1 INTRODUCTION…………………………………………………………………………………….......

5.2 SYNOPSIS OF PREVIOUS CHAPTERS………………….………………………………………….

5.3 GENERAL CONCLUSIONS……………………………………………………………………………….

5.4 IMPLICATIONS OF THE RESEARCH……….………………………………………………………

151

152

153

154

5.5 CRITICAL REVIEW……………………………………….……………………………………………….

5.5.1 Critical review of Phase 1………………….……………………………………………

5.5.2 Critical review of Phase 2…………………..…………………………………………

5.6 RECOMMENDATIONS FOR FURTHER RESEARCH……………………………………………

5.7 FINAL COMMENTS IN CONCLUSION………………………………………………………………

REFERENCES…………………………………………………………………………………….

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160

162

164

166

167

APPENDICES

Appendix A [i]:

Ethical clearance………………………………………………….. 1

Appendix A [ii]:

Permission from provincial departments of health… 2

Appendix B:

Appendix C:

Appendix D:

Letter to provincial departments of health…………… 8

Cover letter to participants……………………………………. 10

Questionnaire…………………………………………………………… 12

Appendix E:

Appendix F:

Appendix G:

Pilot study questionnaire (Phase 1)….……………………. 17

List of variables used in data-analysis……………………. 18

Neonatal communication intervention programme for parents……………………………………………………………….

Neonatal communication intervention programme

20

Appendix G [i]:

Appendix G [ii]: for parents (complete programme)…………………………

Neonatal communication intervention programme for parents Microsoft PowerPoint ™ presentation……

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40

Appendix G [iii]: Handout………………….………………………………………………… 43

Appendix H:

Cover letter and pilot study questionnaire

(Phase 2)…………………………………………………………………. 51

TABLES

Table 1.1: Selected terminology………………………………………………………………………… 13

Table 1.2: Summary of chapters………………………………………………………………… ……… 14

Table 2.1: Summary of the elements of developmental care…………………………… 20

Table 2.2: Team members involved in neonatal developmental care and their roles…………………………………………………………………………………………………. 38

Table 2.3: A selection of programmes and services in the public health sector for the neonatal population in South Africa………………………….

Table 2.4: A selection of tools available for assessment of the high risk neonate’s communication and feeding abilities……………………………… 52

Table 2.5: Locally developed neonatal communication intervention tools……. 53

40

Table 3.1: Number of speech-language therapists and audiologists in provincial hospitals in South Africa…………………………………………………. 66

Table 3.2: Content of the questionnaire…………………………………………………………… 77

Table 3.3: Description of the pilot study………………………………………………………… 82

Table 4.1: Audiologists’ roles in neonatal nurseries (n = 2)……………………………… 101

Table 4.2: Proposed future improvements regarding neonatal communication intervention service delivery (n = 41)……………………………………………… 110

Table 4.3: Audiologists’ needs in neonatal nursery (n = 2)……………………………. 122

Table 4.4: Speech-language therapists’ needs (n = 39)…………………………………. 128

Table 4.5: Speech-language therapists’ roles (n = 39)……………………………………. 129

Table 4.6: Themes included in the programme………………………………………………. 139

Table 4.7: Pilot study of the programme………………………………………………………… 145

Table 5.1: Comparison of ASHA’s guiding principles (2008 [a]) and the

“Neonatal communication intervention programme for parents”. 158

FIGURES

Figure 2.1: Issues that surround the compilation of a neonatal communication intervention tool in South Africa…………………… 18

Figure 2.2: Roles and responsibilities of the speech-language therapist in the NICU (ASHA, 2005; Rossetti, 2001)…………………………………… 48

Figure 3.1: Phases of the research project………………………………………………… 60

Figure 3.2: Professional qualification (n = 41)…………………………………………… 67

Figure 3.3: Provinces where participants are employed (n = 40)……………… 68

Figure 3.4: Years experience in the government sector (n = 40)……………… 68

Figure 3.5: Highest qualification (n = 41)…………………………………………………… 69

Figure 3.6: University where highest qualification was obtained (n = 40). 70

Figure 3.7: Contexts of service provision…………………………………………………… 70

Figure 3.8: Wards where ECI was provided………………………………………………… 71

Figure 3.9: Number of speech-language therapists or audiologists in the speech-language therapy and audiology departments (n = 41) 72

Figure 3.10: Trained interpreters and/or assistants…………………………………. 73

Figure 4.1: Speech-language therapists’ indication of their roles regarding screening and assessment of the infant (n = 39)……

Figure 4.2: Speech-language therapists’ roles in intervention specifically directed at the infant and parents/caregivers (n = 39)…………

Figure 4.3: Speech-language therapists’ roles in intervention specifically directed at staff and team members (n = 39)…………………………

Figure 4.4: Participants’ perceptions of competence in neonatal nursery

99

94

97

(n = 41)…………………………………………………………………………………… 103

Figure 4.5: Participants’ reasons for competence (n = 41)……………………… 103

Figure 4.6: Participants’ enjoyment of their work in neonatal nursery

(n = 41)……………………………………………………………………………………

Figure 4.7: Needs regarding assessment instruments/tools (n = 39)……

Figure 4.8: Needs regarding intervention tools/materials specifically focused on parents or caregivers (n = 39)………………………………

105

117

119

Figure 4.9: Needs regarding intervention tools/materials focused on staff/team members (n = 39)………………………………………………… 121

Figure 4.10: Schematic representation of the content of the programme. 138

Figure 5.1: Implications of the research…………………………………………………… 155

Figure 5.2: Strengths and limitations of Phase 1….…………………………………… 160

Figure 5.3: Strengths and limitations of Phase 2………………………………………. 162

ABBREVIATIONS

ABR – Auditory brainstem response

AIDS – Acquired immunodeficiency syndrome

ASHA – American Speech-language and Hearing Association

BFHI – Baby friendly hospital initiative

CPD – Continued professional development

ECI – Early communication intervention

EI – Early intervention

FASD – Fetal alcohol spectrum disorder

FEFARI – Feeding evaluation form for at-risk infants

HIV – Human immunodeficiency virus

HPCSA – Health professions council of South Africa

JCIH – Joint commission on infant hearing

KMC – Kangaroo mother care

NHCU – Neonatal high care unit

NICU – Neonatal intensive care unit

NIDCAP – Newborn individualised developmental care and assessment programme

OAE – Oto-acoustic emmission

OCI – Observation of communicative intent

PHC – Primary health care

PMTCT – Prevention of mother to child transmission

PPIP – Perinatal problem identification programme

PPP – Pretoria pasteurisation project

ROP – Retinopathy of prematurity

SASLHA – South African speech-, language- and hearing association

SLT & A – Speech-language therapist and audiologist

UNICEF – United nations children’s fund

WHO – World health organisation

Chapter 1

CHAPTER 1

Perspectives on the role of the speech-language therapist and audiologist in the neonatal nursery

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1.1 INTRODUCTION

Early communication intervention (ECI) is an established field within speechlanguage pathology in South Africa and has advanced to include neonatal assessment and management (Fair & Louw, 1999:13; Kritzinger, Louw &

Hugo, 1995:7). The most recent contexts of early intervention service delivery are the neonatal intensive care unit (NICU) and neonatal high care unit

(NHCU) (Rossetti, 2001:171). In South Africa, speech-language therapists are also involved in early intervention services in the kangaroo mother care unit (KMC) as shown by McInroy (2007). Speech-language therapists have a key role to play in the effective treatment of at-risk infants in this unique context (ASHA, 2005:2; Billeaud & Broussard, 2003:83).

Premature and low birthweight infants, and neonates with medical complications who are admitted to the NICU, are at risk for long term medical and neurodevelopmental problems affecting a number of areas, specifically communication and feeding skills (Rais-Bahrami, Short & Batshaw, 2002:85;

Rossetti, 2001:5). Comprehensive management in the neonatal nursery includes not only medical treatment of the infant, but also developmental care and the provision of guidance, counselling and information to the family who are part of the decision-making process regarding the infant’s care (ASHA,

2005:2; Billeaud & Broussard, 2003:83).

The speech-language therapist who practices in the NICU has a varied role and may provide many specialised services, including guidance to staff, parents and caregivers, as well as direct interventions with the neonates in

1

Chapter 1 the form of either communication interaction or parent-guidance and -training regarding feeding and oral-motor exercises (ASHA, 2005:2; Billeaud &

Broussard, 2003:83). Whilst the role of the speech-language therapist in the

NICU is clearly described in international literature (ASHA, 2005:3; Billeaud &

Broussard, 2003:83; Rossetti, 2001:181; Ziev, 1999:33), a lack of guidelines for service delivery in the NICU in the South African sector currently exists

(De Beer, 2003:2).

Speech-language therapists who are employed in South African provincial hospitals are often faced with difficult working conditions, such as a lack of community awareness of services, inadequate instrumentation and tools, limited services of trained interpreters and limited literacy of caregivers (Fair &

Louw, 1999:14; Van Rooyen, 2006:56). The diversity of language and culture in South Africa poses a challenge for speech-language therapists in providing family-centred early intervention services (Louw & Avenant, 2002:145).

According to Swanepoel (2004:16) the first step towards addressing such challenges entails a familiarity with the context from which they arise. As a result, the following complex and layered research question arises: what are the perceptions of speech-language therapists and audiologists, working in

South African provincial hospitals, regarding their role in the neonatal nursery and their current needs in terms of clinical instruments/tools for the provision of neonatal communication intervention services in neonatal nurseries, and furthermore, what is needed in terms of clinical instruments/tools in this context, in order to improve family-centred neonatal communication intervention? An in-depth literature review was conducted in an attempt to shed light on the above questions and in order to formulate a rationale for the proposed study.

AUDIOLOGIST IN THE NICU

The role of the speech-language therapist in the NICU is established and has been widely discussed in international literature (ASHA, 2005:3; Billeaud &

2

Chapter 1

Broussard, 2003:86; Rossetti, 2001:181; Ziev, 1999:33). The speechlanguage therapist is described as a consultant and coach, who informs and encourages parents and staff members, as well as an infant specialist, who provides direct treatment to infants (ASHA, 2005:2; Billeaud & Broussard,

2003:87; Rossetti, 2001:181; Ziev, 1999:33). This intervention is provided to neonates through assessment of communication, feeding or general development, as well as treatment of feeding problems and provision of developmental care (ASHA, 2005:2; Billeaud & Broussard, 2003:88; Rossetti,

2001:181; Ziev, 1999:33).

The speech-language therapist provides information to parents on feeding, with regard to oral stimulation, reducing oral and facial tactile-defensiveness, the benefits of non-nutritive sucking, techniques and strategies to improve oral-motor control and preparing the infant to suck (ASHA, 2005:5; Billeaud &

Broussard, 2003:88). Speech-language therapists also support KMC, which is a relatively recent technique used in South African neonatal nurseries and is proven to decrease hospital stay, shorten periods of time on ventilation, improve milk-production, improve confidence in caretaking and promotes attachment between parent and child (Feldman, 2004:147; Rick, 2006:58;

Rossetti, 2001:191). KMC enhances cognitive development (Feldman,

2004:148) and improves states of alertness, and this results in improved bonding between mother and child and less stress on the mother. This in turn, improves milk production and increases opportunities for socialcommunicative development of the infant (Dippenaar, Joubert & Brussow

Maryn, 2006:16a; Rossetti, 2001:191).

Speech-language therapists and audiologists educate parents and family on the appropriate interactions with the neonate. They inform parents and caregivers how to recognise the neonates’ stress behaviours, how to reduce interactional demands, the significance of eye contact and the importance of talking to the infant so as to appropriately stimulate the infant’s communication development and prevent communication developmental delays (ASHA, 2005:3; Billeaud & Broussard, 2003:88; Rossetti, 2001:174).

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Chapter 1

Approximately 5 – 12% of infants are treated in an NICU, but these newborns account for 40 – 70% of all cases of early onset sensorineural hearing loss

(Hess et al., 1998:82). The paediatric audiologist’s basic role is detection of hearing problems, evaluating hearing and intervention in the form of amplification (Roush, 1991:49). The NICU, together with the well-baby nursery, are established newborn hearing screening (NHS) contexts (Cox &

Toro, 2001:99–104; Hess et al., 1998:81–89). According to Swanepoel,

Delport and Swart (2004:634) NHS can be justified for the following reasons: the prevalence of hearing loss is higher than other birth defects, undetected hearing impairment leads to irreversible language and cognitive delays with far-reaching socio-economical ramifications, and early intervention yields dramatic benefits for infants identified before six months of age, than for those identified later. Developmental screening and follow-up services are therefore of the utmost importance.

The role of speech-language therapists and audiologists also includes the organisation of follow-up services and the compilation of family-centred early intervention programmes for treatment after the child has been discharged

(ASHA, 2005:10; Billeaud & Broussard, 2003:87; Rossetti, 2001:181; Ziev,

1999:33). The speech-language therapist has a responsibility towards staff members of the NICU for continued education and in-service training

(Rossetti, 2001:182) especially regarding the relationship between the neonate’s early experiences and communication development (Billeaud &

Broussard, 2003:88). This professional function implies the involvement of the speech-language therapist and audiologist in a inter- or transdisciplinary team approach where the therapist attends ward rounds, team discussions, ongoing needs assessments and discharge planning (ASHA, 2005:10;

Billeaud & Broussard, 2003:92; Rossetti, 2001:182; Ziev, 1999:33). The role of the speech-language therapist and audiologist working in the NICU is therefore complex and varied, and requires a sound theoretical underpinning and as well as experience, such as clinical skills gained from experiences in

NICUs.

4

Chapter 1

However, due to a number of reasons, the ideal role described above does not always occur in the South African context as it does in developed contexts. Neonatal communication intervention services in the local context are discussed forthwith in order to illustrate the impact of the context specific challenges on speech-language therapists working in neonatal nurseries.

1.3 ECI IN THE NEONATAL NURSERY IN THE SOUTH AFRICAN

CONTEXT

The earliest intervention for infants at-risk for a communication delay is provided in the NICU (Rossetti, 2001:270). In South Africa, in the public health sector, ECI services to neonates are less developed and less comprehensive in comparison to a developed country such as the USA

(Kritzinger et al., 1995:7). Whilst international literature provides guidelines on the speech-language therapist’s service-delivery in the NICU (ASHA,

2005), the local literature shows a shortage of information on the current service delivery practices and roles of speech-language therapists in the

NICU and NHCU in South Africa (De Beer, 2003:2).

In South Africa, neonatal care is provided in both public as well as in private health care institutions. The South African public health structure consists of three levels of health care. The first level, primary health care (PHC), refers to care being provided to patients at community-based clinics by PHC nurses and in some cases, doctors (South African Government Information, 2006).

Patients are referred to district or regional provincial hospitals for treatment, which could not be provided at PHC level. The third level, tertiary hospitals, refers to hospitals that provide specialized care such as cardiology or renal dialysis (South African Government Information, 2006).

In the South African public sector, neonatal care is provided at district and regional hospitals in NHCU and KMC units. These units provide intensive care to premature and low birthweight infants as well as other infants who require additional attention (Billeaud & Broussard, 2003:85). Tertiary hospitals, which are also described as teaching hospitals, provide neonatal

5

Chapter 1 care in NICUs that have sophisticated treatment and high-technology equipment (Billeaud & Broussard, 2003:85). As soon as the infant does not need specialist care anymore, he/she is transferred to a step-down unit – usually a NHCU or a KMC unit – until the infant attains full-term age, achieves adequate heart rate and feeds orally adequately (Billeaud & Broussard,

2003:86; Dippenaar et al., 2006:16).

Furthermore, since 2003, it became compulsory for newly graduated allied health professionals such as speech-language therapists and audiologists to provide services in a government facility for a minimum of one year before being allowed to practice independently (South African Government

Information, 2006). This implies that newly qualified professionals are providing services in all areas of speech-language therapy and audiology in the hospital and surrounding PHC clinics and consequently also in NICU,

NHCU and KMC units. According to Rossetti (2001:174) this area of service delivery requires specialist knowledge in order to provide effective services.

South Africa can be viewed as a continuum of a developed as well as a developing context (Fair & Louw, 1999:13). Professionals providing ECI services in local provincial hospitals, and consequently the neonatal nurseries of provincial hospitals, are therefore challenged by numerous factors unique to this context.

Speech-language therapists and audiologists are faced with large caseloads as there are limited qualified professionals employed in provincial hospitals.

According to Fair and Louw (1999:16) a dearth of speech-language therapists exists in South Africa. The introduction of the ‘community service’ year has expanded services as more speech-language therapists and audiologists are now working in the neonatal nurseries in provincial hospitals. However this in itself is not a feasible solution as these speech-language therapists and audiologists have limited clinical experience, and in most cases practice without the supervision of more experienced speech-language therapists.

6

Chapter 1

Another challenge to ECI service provision in the neonatal nurseries of provincial hospitals is multilingualism. The multicultural and multilingual nature of the communities in South Africa poses a challenge in delivering intervention to the clients in their caseload, as more than eleven languages are spoken in South Africa, where each linguistic group has their own cultural practices (Louw & Avenant, 2002:146; Fair & Louw, 1999:16; Ligthelm,

2001:2). Speech-language therapists and audiologists working in this context may find it problematic to communicate effectively with the infant’s families and caregivers. The use of interpreters is a possible solution, but currently there is an insufficient number of trained interpreters in the public health sector (Louw, 2007 [b]), which may compromise the quality of ECI services rendered (Lynch & Hanson, 1998:78).

In an attempt to overcome communication and cultural barriers, informal interpreters are often utilised by speech-language therapists and audiologists working in neonatal nurseries. According to Van Rooyen (2006:31) who targeted a sample of speech-language therapists and audiologists performing

ECI in their community service year, found most of the respondents had access to informal interpreters only. Informal interpreters may not always have the required knowledge to convey the message accurately and correctly from the speaker to the listener (Lynch & Hanson, 1998:79), which once again impacts on the quality of services provided.

Furthermore speech-language therapy and audiology service delivery in the neonatal nursery is influenced by the fact that written information and home programmes cannot be provided to many families and caregivers (Van

Rooyen, 2006:27) as they present with limited literacy skills. Louw, Shibambu and Roemer (2006:52), who explored culturally diverse families’ participation in the team approach toward their children with cleft lip and palate and craniofacial anomalies, found that only 54% of the participants in their study were literate. Limited literacy of caregivers is viewed to be an environmental risk for the development of a communication delay for infants in their care

(Fair & Louw, 1999:14).

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Chapter 1

Many infants who receive treatment in the NICU are discharged for follow-up treatment and developmental screening as out-patients. This poses a challenge to speech-language therapists and audiologists who provide services to this population, as many infants and their caregivers have poor return rates for appointments. According to Fair and Louw (1999:13) poor return rates result from a wide geographical distribution of infants with special needs as well as problems with finances and transport (Van Rooyen,

2006:42), which is a hindrance to the implementation of effective ECI services. According to Swanepoel et al. (2004:634) screening programmes in general, especially hearing screening programmes, are not common practice in South Africa and are not meeting the needs of the people.

ECI services by speech-language therapists and audiologists are also influenced by other professionals in the provincial hospital’s NICU-team.

Limited awareness of the role of the speech-language therapist by other team members compromises ECI service provision in this context. Rakau

(2005:40), who targeted mothers of infants in the NICU of a provincial hospital in Pretoria, concluded that there appears to be a lack of multi-professional team involvement in the NICU and that speech-language therapists in her study were not optimally involved in this context. According to Kritzinger

(2000:23) all three levels of public health care are based on the principle of a coordinated referral system. Optimal ECI services should be provided through a transdisciplinary teamwork approach (Rossetti, 2001:119). It is clear that neonatal ECI will be unfavourable if team members are not familiar with the valuable role speech-language therapists and audiologists could play in the context of the neonatal nursery.

To further complicate service delivery, the speech-language therapist and audiologist working in the NICU often do not have appropriate instrumentation, e.g. video-fluoroscopy and materials for comprehensive evaluations and intervention. This was also noted by Van Rooyen (2006:50) who found that few of the respondents in her study had access to appropriate audiological equipment for newborn hearing screening and diagnostic hearing testing at the institutions where they were employed as community service

8

Chapter 1 therapists. A shortage of clinical instruments with relevant procedures in ECI exists that can be used in neonatal service provision in the South African context (Kritzinger & Louw, 2003:11).

An exciting development in neonatal communication intervention is that comprehensive undergraduate training is taking place. According to

Kritzinger and Louw (2003:5) ECI is included in all undergraduate programmes of universities offering programmes in speech-language therapy and audiology. However, clinical expertise is not always sufficient to meet the complex needs of infants, families and team members. Community service therapists in Van Rooyen’s study (2006:57) stated that they received adequate training to fulfil their roles, but indicated a need for further training in working across language barriers and providing services in non-ideal circumstances. Therefore continued professional development has an important role to play for both new and more experienced graduates.

ECI services are expanding to include universal NHS at provincial hospitals.

According to Swanepoel et al. (2004:634) a Hearing Screening Position

Statement was conceptualised by the Professional Board for Speech,

Language and Hearing Professions of the Health Professions Council of

South Africa and is based on the Joint Commission on Infant Hearing in the

USA Year 2000 Position Statement. This Position Statement proposes screening of high risk infants, using targeted hearing screening before discharge from hospital or at the six week immunisation visit, so as to initiate intervention before six months of age (Swanepoel et al., 2004:634).

In conclusion, it is apparent that although many barriers exist to service delivery of neonatal ECI in provincial hospitals, innovative strategies can be employed to bring speech-language therapy and audiology services closer to the ideal service provision. By providing family-centred services and by working in a transdisciplinary team, neonatal communication intervention services may be improved to the benefit of this vulnerable population.

9

Chapter 1

1.4 ENHANCING NEONATAL COMMUNICATION INTERVENTION

SERVICES

ASHA (2005:2) advises that family-centred care is a key principle of neonatal communication intervention and involves compassionate, open and total inclusion of the family in the care and decision-making process for their infant.

By following a family-centred approach, a child with special needs is provided with a management plan that involves the entire ecosystem (family and community) in which he or she lives (Billeaud, 1998:77).

A family-centred approach to ECI in the neonatal nursery does not always materialise in the local context, due to certain hindrances. Speech-language therapists and audiologists can utilise innovative methods to make the neonatal ECI services they provide more individualised and family-centred. A study conducted by Packery-Babamia (2001:60) targeted mothers with infants in the NICU of a provincial hospital in South Africa, found that mothers expressed the preference that they would rather interact with interventionists that are of the same religious, cultural and linguistic background as themselves. As this is not always possible, the speech-language therapist can be aware of and sensitive to such needs and provide culturally appropriate education and counselling opportunities to families in the NICU

(Packery-Babamia, 2001:67; Rakau, 2005:42). Best practice in early intervention is defined as being family-centred and culturally sensitive

(Iglesias & Quinn, 1997:69; Weitzner-Lin, 2004:4) and the application thereof in the context of the NICU of a provincial hospital is therefore indicated.

ECI service provision should be comprehensive, coordinated and team-based

(ASHA, 2008:2). A transdisciplinary approach to intervention implies that each team member will retain his/her own disciplinary expertise, while benefiting from the knowledge and experience of the other disciplines

(Rossetti, 2001:180). Due to certain challenges speech-language therapists and audiologists face in neonatal nurseries of provincial hospitals, limited transdisciplinary teamwork is taking place. This is indicated by Rakau

(2005:40) who found that no speech-language therapists were involved in the

10

Chapter 1

NICU where her study was conducted. De Beer’s findings (2003:59) also indicated that speech-language therapists did not effectively fulfil their role within the NICU-team, due to isolated service delivery and limited transdisciplinary teamwork.

Neonatal communication intervention services in provincial hospitals may be improved by providing treatment within a transdisciplinary team and directing intervention at all parties concerned. A transdisciplinary team approach to

ECI is highly successful and is the future of early intervention (Rossetti,

2001:119). The development of collaborative partnerships between speechlanguage therapists and their team-members is imperative for marketing of

ECI services for at-risk infants (Moodley, Louw & Hugo, 2000:37). By aiming intervention at the infant, parents and the NICU-staff, a holistic approach to intervention is utilised, which ensures the best results for the infant and family

(McInroy & Kritzinger, 2005:33).

1.5 CONCLUSION AND RATIONALE

Local literature shows a shortage of information on the current service delivery and roles of speech-language therapists and audiologists in neonatal nurseries in the South African context. The literature review revealed that the role of speech-language therapists and audiologists in this context is currently different to that described in international literature. While some of the professional functions that speech-language therapists and audiologists fulfil in the neonatal nurseries do materialise according to international guidelines, some of these functions are a challenge to apply to the local context, such as providing parents with information needed and counselling in the preferred languages.

In order to improve the quality of neonatal communication intervention service delivery in provincial hospitals in South Africa, it is necessary to conduct a needs analysis in order to establish whether a specific neonatal communication intervention tool is necessary to overcome some of the barriers mentioned. The main aim of the current study is therefore to compile

11

Chapter 1 a preliminary neonatal communication intervention instrument/tool, which is locally relevant and for use by speech-language therapists in neonatal nurseries of provincial hospitals in South Africa.

1.6 DESCRIPTION OF TERMINOLOGY

A brief description of certain terms used throughout this study is provided in

Table 1.1.

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Chapter 1

Table 1.1: Selected terminology

Term

Neonate

High risk infants or neonates

Neonatal communication intervention tool

Provincial/public hospital

Neonatal intensive care unit (NICU)

Kangaroo mother care (KMC)

Neonatal nurseries

Developmental care

Early communication intervention (ECI)

Description

A neonate is an infant who is less than 28 days old (Harrison,

2002:1). For the purpose of this study, a neonate is defined as any infant receiving neonatal care.

A high risk infant or neonate can be defined as an infant or neonate at biological or environmental risk for a developmental delay and more specifically a communication development delay

(Rossetti, 2001:5; McInroy, 2007:12).

The NICU is a sophisticated nursery where infants who require specialised surgical or medical interventions, are treated

(Billeaud & Broussard, 2003:86).

KMC is an intervention where the mother holds the infant on her chest (skin-to-skin contact) and feeds the infant breast milk on demand. KMC improves the quality of care and mortality rates of low birthweight and premature infants, achieving cost saving in all settings, whether public or private, primary or tertiary, and developing or developed countries (Hann, Malan, Kronson,

Bergman & Huskisson, 1999:37; Pattinson, Bergh, Malan &

Prinsloo, 2006:1).

For the purpose of this study, the term neonatal nurseries will be used collectively to refer to the neonatal intensive care unit

(NICU), neonatal high care unit (NHCU) and the kangaroo mother care ward (KMC).

Developmental care is an intervention strategy used in the NICU to help mediate some of the risks for premature infants and their families. When an infant’s cues suggest over-stimulation and disorganisation, caregivers will use strategies such as positioning and reduction of stimulation to help the infant self-regulate

(Goldberg-Hamblin, Singer, Singer & Denney, 2007:164).

ECI is intervention, including both assessment and treatment, provided to families and their children below the age of three years, who demonstrate, or are at risk of demonstrating either a disability or delay involving communication, language, speech or prerequisite oral-motor behaviour, with the aim of establishing an interactive relationship between the infant and his/her environment (Louw, 1997:1; Rossetti, 2001:5; McInroy, 2007:14).

A neonatal communication intervention tool is a clinical instrument used to conduct assessments or provide treatment of aspects pertaining to the infant, parent/caregiver guidance or staff/team education in neonatal nurseries.

For the purpose of this study a provincial/public hospital is defined as a secondary or tertiary South African government hospital where medical, surgical and rehabilitation services are provided to patients.

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Chapter 1

1.7 CHAPTER OUTLINE

The chapters that are contained in this dissertation are summarised in Table

1.2.

Table 1.2: Summary of chapters

Name of chapter

Chapter 1:

Perspectives on the role of the speechlanguage therapistand audiologist in the neonatal nursery

Chapter 2:

Best practice in neonatal care in South

Africa

Chapter 3:

Methodology

Chapter 4:

Results and discussion

Chapter 5:

Conclusion and recommendations

Contents

This chapter introduces the topic of ECI services in the neonatal nurseries in South Africa and provides the background from which the research question arose.

The current role of the speech-language therapist in the NICU in recent literature is described.

Neonatal communication intervention in neonatal nurseries in South Africa is reviewed.

A problem statement and theoretical rationale for the study is formulated.

Terminology used in the study is thoroughly discussed.

An outline of all chapters included in the study is depicted in table format.

A critical review of literature provides current perspectives on ECI in neonatal nurseries.

A clear argument is provided on the reasons why research in the field of neonatal communication intervention in South Africa is necessary.

This chapter describes the way in which the research was conducted according to literature.

The research was conducted in two phases and is described as follows:

Phase 1: Speech-language therapists’ perceptions of their role and their needs in neonatal nurseries in

South Africa.

Phase 2: Compilation of a tool for use in neonatal nurseries in South Africa.

In this chapter the results are documented according to the previously formulated objectives and displayed in tables and graphs. The results are interpreted according to recent literature.

This chapter draws conclusions highlighted by the results in the previous chapter and will refer to the research problem statement in Chapter 1.

The meaning and value of this study’s contribution is highlighted and discussed.

Recommendations and implications for future research within this field of study are documented.

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Chapter 1

1.8 SUMMARY

Chapter 1 describes the role of the speech-language therapist in neonatal nurseries in South Africa. A research problem was identified and a research question was posed. The current study aims at contributing to the shortage of information regarding the role of the speech-language therapist and audiologist in neonatal nurseries. ECI within the context of neonatal nurseries in South Africa was depicted and best practice in this context was described.

The need for culturally and contextually appropriate tools for use in this context was expressed. A description of terminology as well as relevant concepts are provided together with an outline of the chapters included in the study.

15

Chapter 2

CHAPTER 2

Best practice in neonatal care in South Africa

_______________________________________________________________________________________________

2.1 INTRODUCTION

Rapid advances in research, as well as new discoveries integrated with existing knowledge, necessitate the continuous adaptation of early communication intervention (ECI) strategies and methods in order to achieve best practice

(Kritzinger, 2000:35). Current progress in acute neonatal care has resulted in improved survival rates for low birthweight and premature infants and, according to Rossetti (2001:173), the question is now no longer whether infants can be saved, but rather if we as professionals can improve the survivors’ developmental outcome. Speech-language therapists working in the neonatal intensive care unit (NICU) provide a number of services, all of which require specialised preparation (Billeaud & Broussard, 2003:83).

Currently speech-language therapists are called upon to integrate research evidence, clinical expertise and client values into clinical decision-making to demonstrate evidence-based practice (Johnson, 2006:20). According to

Johnson (2006:24) evidence-based practice guidelines help practitioners in clinical management of specific health care or mental health issues, by indicating courses of action that are supported by evidence. Guidelines for ECI in South

Africa were compiled by SASLHA (Louw, 1997) but currently there are no specific guidelines for speech-language pathology in the NICU in South Africa.

The Roles and Responsibilities of Speech-Language Pathologists in the

Neonatal Intensive Care Unit: Guidelines by ASHA (2005) may be used as a general guide, although many contextual differences prohibit direct application.

16

Chapter 2

The current situation emphasises the need for appropriate guidelines for speechlanguage therapists providing services in NICUs in South Africa.

Guidelines need to be used by speech-language therapists involved in all contexts to inform assessments and clinical decision-making during intervention.

In the NICU speech-language therapists are involved in assessments of, and intervention for the communication as well as the feeding abilities of the infant, as well as parent and caregiver education and counselling (ASHA, 2005:2).

Assessment instruments are designed to collect samples of behaviour and are a means of structuring observations and reporting results (Rossetti, 2001:93). A valid assessment of an individual’s communicative abilities and disabilities is the foundation on which all future clinical activities are based (Shipley & McAfee,

1998: xiii). ECI assessment tools are utilised to identify risks for a communication delay or disorder as early as possible, to decide on an appropriate course of action for further treatment, to determine the frequency and length of treatment, to identify the need for referral to other professionals, to support evidence-based practice and to monitor change in the infant as well as family or caregivers over time (Rossetti, 2001:88). Once intervention planning for the individual infant and family has been done, the speech-language therapist may also make use of intervention tools for training and guiding other team members involved in developmental care. Speech-language therapists are responsible for caregiver guidance as well as for staff and/or team education within a developmentally supportive care approach in the neonatal intensive care unit-context (ASHA, 2005:2).

NICU-based services should be delivered within a family-centred and culturally appropriate approach (ASHA, 2005:2), which necessitates that tools and programmes used in this context need to be congruent with this approach.

Currently few neonatal communication assessment and intervention tools have been compiled or developed specifically for the local context. Available literature has identified limitations regarding culturally appropriate clinical instrumentation

17

Chapter 2 for ECI in public hospitals in South Africa (Kritzinger & Louw, 2003:11; Louw,

2007:66, [b]; Van Rooyen, 2006:50), which hampers the provision of familycentred and culturally appropriate services. The availability of neonatal communication intervention tools for use in public hospitals’ neonatal nurseries in

South Africa will be reviewed in an attempt to justify the development of a tool in the local context. The following framework was conceptualised for this purpose.

The aspects presented in Figure 2.1 were identified as being relevant to the topic and will be discussed forthwith.

Best practice in developmental care

- Evidence-based practice in international literature

ECI in SA

- Assets

- Barriers

Developmental care in SA

-

High risk population

- Professions involved

- Programmes & services

Neonatal communication intervention tool

- Role of speech-language therapist

- Current situation in SA

Figure 2.1: Issues that surround the compilation of a neonatal communication intervention tool in South Africa

18

Chapter 2

Clinical tools for neonatal ECI can be understood better and utilised more effectively in clinical practice if their theoretical foundation is investigated. The aim of this chapter is to serve as a theoretical underpinning for the viability of compiling a neonatal communication intervention tool for use in public hospitals in South Africa.

2.2 THEORETICAL UNDERPINNING FOR A NEONATAL COMMUNICATION

INTERVENTION TOOL

This section provides the theoretical underpinning for the development of a neonatal communication intervention tool by examining best practice within developmental care as well as ECI in South Africa, using an asset-based approach.

2.2.1 Best practice in developmental care

Kenner and McGrath (2004: xi) describe developmental care as “…an

intuitiveness to observe the infant and family and their interactions with the environment. It is a framework for providing care that supports the

neurobehavioural development of the infant.” According to Goldberg-Hamblin,

Singer, Singer and Denney (2007:165) common elements of developmental care include neonatal nursery systemic practices as well as individual nursing-infant interactions. This is displayed in Table 2.1 together with parent practices compiled from Rossetti (2001:182).

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Chapter 2

Table 2.1: Summary of the elements of developmental care

Neonatal nursery practices

1. Lighting dimmed and sound

reduced:

Preferably utilising natural light, establishing day-night cycles, using isolette covers, elimination of radios, audible heart rate monitors, audible talking, audible cleaning equipment.

2. Clustered care:

Medical and regular procedures should be clustered together so that infant has longer periods of undisturbed rest.

Nursing practices

1. Positioning and swaddling:

Infant positioned in flexion during sleep with use of blanket rolls, padding and nests.

3. Primary care nursing:

Infant is assigned a team of several nurses for the duration of the stay in the unit.

2. Assessment of infant state and competencies:

Nurse understands infant’s facial expression and motoric cues to know whether infant is stressed. Nurse also observes whether infant can selfregulate when stressed.

3. Reducing over-stimulation and stress:

Reducing movement, handling, light, noise. Assisting infant to self-soothe and/or suck on hands/pacifier.

Encouraging Kangaroo Mother Care.

4. Family-centred care:

Parent involvement, open visiting policy, warm atmosphere, discharge training, and encouraging kangaroo mother care.

4. Providing appropriate interaction:

Engaging in eye contact and communication with infant when infant is most capable of interacting.

Compiled from Goldberg-Hamblin et al. (2007:165) and Rossetti (2001:182).

Parent/caregiver practices

1. Ownership of their infant:

Learn about their infant and the manner in which the environment affects their child.

2. Socio-communication interaction:

Identify and interpret infant’s unique signals (e.g. stress, avoidance, engagement). Interact at appropriate time by providing language stimulation through use of descriptions or praise.

3. Caring for infant:

Caring for, touching and holding infant as much as possible while infant is hospitalised. Assisting infant to selfregulate by using calming techniques

(swaddling, positioning and nonnutritive sucking).

4. Kangaroo mother care:

Providing tactile-kinesthetic stimulation through skin-skin contact with infant.

20

Chapter 2

Best practice in developmental care in neonatal nurseries is described comprehensively in research from the United States of America. According to

Bozzette and Kenner (2004:75) more than 80% of 500g – 800g infants are surviving today due to advances in medical care. In spite of improved technology that reduces mortality rates of preterm infants, these infants are exposed to more stressors than full-term neonates and present with stress levels above their ability to cope (Hennessy, 2006:13). These infants are also characterised by difficult temperaments owing to an underdeveloped nervous system, and therefore these infants are easily overwhelmed by the NICU itself

(Goldberg-Hamblin et al., 2007:163). Als (1997:47) states that not only should survival of these infants be ensured, but optimal development also has to be fostered as infants born prematurely and with low birthweight may experience a multitude of difficulties including school failure, health problems and disability

(Goldberg-Hamblin et al., 2007:163).

NICUs have been involved in profound transformations since the mid-1980s by moving from a task- and teaching-orientated model towards a model characterised by family-centred developmentally supportive care (Als, 1997:55).

This is attributed to the importance of establishing an alliance between parents and professionals, which supports the parents’ cherishing of the infant (Als,

1997:55). According to Klaus and Fanaroff (2001:224) neonatal nurseries have become concerned about the negative effects of the NICU environment and have started implementing preventative strategies to reduce noxious stimuli and to promote positive development. Rossetti (2001:276) states that researchers have shifted attention from improving survival rates of high risk infants to studying ways to improve developmental outcomes for these infants.

Within the developmental care approach, infants are viewed to be active participants in their own care and are focused on interventions that protect the premature or sick infant’s immature central nervous system (Als, 1997:57; Klaus

& Fanaroff, 2001:224). According to Hennessy (2006:14) the preterm infant’s

21

Chapter 2 developing brain is known to be particularly vulnerable to a stressful environment and the NICU environment may overwhelm the premature infant (Goldberg-

Hamblin et al., 2007:163). Negative sequelae of this environment on the infant’s developing brain can be reduced through developmental care, as it provides a simple and effective way of reducing complications by modifying the environment to which the infant is exposed (Hennessy, 2006:14).

Several research studies have confirmed the evidence-based practice of developmentally supportive care and have found that a developmentally supportive environment leads to increased weight gain, shorter stays in hospital, shorter time on ventilators (Bozzette & Kenner, 2004:79), improved medical as well as behavioural outcomes, improved brain and motor development (Als,

1997:62). Rossetti (2001:276) concludes that developmental care not only dramatically improves developmental trajectories for infants admitted in the

NICU, but also provides improved medical benefits and cost savings. American researchers such as Als (1997:62) have made major contributions to the implementation of developmental care and the provision of high quality evidence of effectiveness as seen from studies mentioned forthwith. Therefore research and applications of developmental care in the United States of America may be viewed as an example of what best practice entails.

A programme that has shown positive results for premature infants is the

Newborn Individual Developmental Care and Assessment Programme (NIDCAP)

(Als et al., 2004). This programme was developed as a framework for the implementation of developmental care for premature infants (Als, 1997:57; Klaus

& Fanaroff, 2001:224). NIDCAP is a comprehensive approach to developmentally supportive care as well as care which is individualised to goals that have been set according to each infant’s level of stability (www.nidcap.org).

Als (1997:57) states that this approach is a systematic method to observe the infant’s behaviour and is conducted by a developmental professional, who then provides suggestions for ways to understand and analyse the infant’s

22

Chapter 2 physiological stability, behavioural organisation and developmental progression.

Evidence of enhanced brain function as well as brain structure in preterm infants between 28 and 32 weeks gestational age was determined and attributed to

NIDCAP (Als et al., 2004:846). Kleberg, Hellström-Westas and Widström

(2007:409) concluded that mothers of preterm infants who received care according to the NIDCAP approach felt closer to their infants than mothers whose infants received conventional care. The NIDCAP approach requires indepth training at any of the seventeen NIDCAP training centres in the USA,

South America and Europe (www.nidcap.org). Although NIDCAP provides a highly valuable resource in support of developmental care, it typically takes 12 months to complete the compulsory training (www.nidcap.org). It is therefore not readily accessible to developmental professionals in South Africa and as a result it is also not implemented in local neonatal nurseries. NIDCAP is viewed as best practice within developmental care and although few professionals are NIDCAPtrained, all professionals involved still have a responsibility to implement the elements of developmental care in neonatal nurseries where they work, since the results thereof have been proven. Kangaroo mother care (KMC) is a viable alternative for the South African context and it may assist in overcoming the barrier of lengthy and expensive training required by NIDCAP. KMC is a multidisciplinary developmental care practice that has been researched and found to be effective and safe.

KMC is a developmental care practice and form of tactile-kinesthetic stimulation and is described as early, prolonged and continuous skin-to-skin contact between mother and the low birthweight infant, in hospital and after discharge, with exclusive breastfeeding (Cattaneo, Davanzo, Bergman & Charpak,

1998:279; Rossetti, 2001:190). According to Cattaneo et al. (1998:281) KMC results in savings due to reduced need for sophisticated equipment and an earlier discharge. KMC is also used for rewarming mildly or moderately hypothermic low birthweight infants and for transport between healthcare facilities (Cattaneo et al., 1998:281). KMC has been shown to be a safe

23

Chapter 2 alternative for Third World countries where 96% of the world’s premature infants are born (Bergman, Linley & Fawcus, 2004: 784). The effectiveness and safety of KMC is well established and is rapidly becoming an integral part of the care of newborn infants worldwide (Bergman, Malan & Hann, 2003:312) and is regarded as an important developmental care practice for developing contexts also

(Bergman et al., 2004:784).

According to Rossetti (2001:276) implementation of the developmental care approach is no longer optional. NICUs choosing not to do so must have clear reasons or they should at least conduct their own trials in an attempt to implement this approach (Rossetti, 2001:276). ASHA (2005:2) stipulates that developmental care is a key principle for speech-language therapists performing their roles and responsibilities in the NICU.

The benchmark for ECI service delivery in neonatal nurseries is neonatal communication intervention within a developmental care approach. A description of the characteristics of general ECI services in the South African context is required in order to identify and understand the differences as compared to the situation in developed contexts. This will serve to illustrate the need for the development of culturally and contextually appropriate materials.

2.2.2 ECI service delivery in South Africa

In order to describe ECI in general within the South African context, assets of service delivery as well as barriers that exist in the local context will be identified.

An asset-based approach emphasises positive aspects in this context that can be utilised to improve service delivery. According to Eloff and Ebersöhn

(2001:150) the asset-based approach is also referred to as the “half-full glass” approach to intervention. This approach to intervention focuses on what is currently present and what are the capacities inherent to the individuals and environment, without starting with what is lacking or problematic (Eloff &

24

Chapter 2

Ebersöhn, 2001:151). Therefore the differences and similarities between ECI in

South Africa and the ideal situation described in international literature will be investigated according to an asset-based approach. This approach will provide a representative overview of South Africa’s assets to address barriers within the context of ECI.

Firstly, the fact that the national health care system in South Africa was transformed to a Primary Health Care (PHC) system in 1997 is viewed as a positive characteristic of service delivery in South Africa, as it aims to bring health care as close to community members’ homes and work settings as possible (Hugo, 2004:7; Swanepoel, 2004:11). The goal of the South African

Health Policy is to meet the health needs of the whole population with the focus on health care rather than medical care (Swanepoel, 2004:11). Health care facilities providing primary health care are placed within communities, providing a potential platform from which to launch early intervention services in all communities, both developed and developing (Fair & Louw, 1999:17). According to Fair and Louw (1999:22) the dire need for ECI services in the developing context of South Africa may be met by implementing an integrated model of ECI through community-based intervention.

Another asset of ECI service delivery in South Africa is the institution of a compulsory community service year for health care professionals for one year post-graduation, which is contributing to the expansion of ECI services within

South Africa (South African Government Information, 2006). This implies that speech-language therapy services are now available in areas that were not reached previously. Research conducted by Van Rooyen (2006:55) and Louw

(2007:65, [b]) found that ECI services in the public health care system are expanding and in South Africa more people are being reached due to community service therapists.

A further strength of ECI service delivery in South Africa is that all undergraduate

students in speech-language therapy and audiology in training institutions in

25

Chapter 2

South Africa are exposed to and trained in ECI. The fact that ECI has been included in all undergraduate programmes in speech-language therapy

(Kritzinger & Louw, 2003:5) is viewed to be beneficial to the development of the field within South Africa. The implication is that all newly qualified speechlanguage therapists and audiologists are better equipped and more adequately prepared than their predecessors to render thorough ECI services. This leads to improved quality of ECI services and increased benefits for children and their families requiring services.

An additional strength of ECI in South Africa is the fact that local research is emerging and studies have been conducted on the characteristics of the population requiring ECI (Ligthelm, 2001; Louw, Shibambu & Roemer, 2006;

Rakau; 2005) service delivery models (Fair & Louw, 1999; Kritzinger, 2007;

Popich, 2003), and assessment protocols (Kritzinger, 1996; Kritzinger & Louw,

2003). This emerging research base is viewed to be a strength as it validates the practice of ECI in the local context and provides guidelines for best practice, even though empirical research data for evidence-based practice in ECI in South

Africa is still extremely limited.

From the above discussion it is clear that ECI in South Africa is characterised by certain assets, however, in comparison to best practice described in the literature from the USA, Canada or Britain, ECI in South Africa is still in a developing phase. The section that follows is an asset-based perspective of certain barriers that speech-language therapists may be confronted with when providing ECI in

South Africa.

Legislation in the USA (PL 99-457) mandates early intervention services to infants and toddlers with special needs, which resulted in expansion in these early intervention services by placing emphasis on families, coordinating community services and supports, and fostering parent-professional partnerships

(Guralnick, 1997:5). Current health care policies in South Africa prioritise care of mothers and young children, as can be seen in recent legislation that

26

Chapter 2 emphasises the provision of free primary health care to children under the age of six years (National Health Act, 2003). Although this includes the provision of

ECI, it is still not a health care priority in South Africa. This is not only due to the

HIV and AIDS pandemic, but also to the limited knowledge about the benefits of

ECI, limited access to ECI facilities, shortage of ECI facilities and early communication interventionists, a limited referral system and poor team-work

(Kritzinger, 2000:8). Although the importance of the early years is emphasised in policies such as The White Paper on Disability in 1997, which has been adopted to support intervention services to young children (Alant & Harty, 2005:79), there are limited resources available in South Africa. Issues such as unemployment and lack of housing are regarded as funding priorities and this limits the relevance of certain service delivery models, created in developed contexts such as the USA, Canada and Britain, for South Africa (Fair & Louw, 1999:16).

Cultural richness in ECI in South Africa may affect the quality of service delivery.

Cultural diversity has a profound impact on the ways in which professionals and families interrelate and participate in treatment programmes (Louw et al.,

2006:47). In a study conducted by Louw (2007:65, [b]) regarding ECI service delivery in public hospitals in four provinces in South Africa, it was concluded that some of the high risk infants and families were still not receiving culturally appropriate services. In the United States of America a similar situation arises.

Madding (2000:11) reported that there is no state in the USA devoid of linguistically and culturally diverse populations and therefore professionals have been challenged to interact effectively with parents as well as children. Hence cultural constraints are not unique to the South African context, but this aspect still needs to be addressed in ECI service provision. Local speech-language therapists can therefore look to international efforts for guidelines on this aspect.

Professionals need to be aware of and sensitive to belief systems, whether they are scientific or traditional, as a family’s views of disability will affect their view of early intervention services and choice of treatment and will affect family

27

Chapter 2 involvement in intervention (Zhang & Bennet, 2001:152). Lynch and Hanson

(1998:49) define cross-cultural competence as “the ability to think, feel and act in

ways that acknowledge, respect, and build upon ethnic, (socio) cultural, and

linguistic diversity”. Louw et al. (2006:54) stated that by following an assetbased approach, applying knowledge based on research and recognizing family uniqueness, families of any culture may be empowered to participate in treatment to support their children. In South Africa many opportunities exist for speech-language therapists to become culturally competent in order to effectively reach the infants and young children who are in need of services.

However, it is not clear whether therapists are in fact developing these skills by utilising the above-mentioned guidelines.

The diversity of South Africa’s population can also be seen in the variety of languages people are using. South Africa has eleven official languages of which

Zulu is the most commonly spoken (24%) with Afrikaans third (13%) and English fifth (8%) (Population Census Key Results, 2001). Currently the majority of speech-language therapists in South Africa are from English or Afrikaans speaking backgrounds (Pakendorf, 1998:2). Naturally, therapists are aware of, but not necessarily familiar with the linguistic and cultural background of African cultures, which poses a major challenge in delivering equitable services (Overett

& Kathard, 2006:54). The multilingual nature of the people of South Africa may be viewed as challenging to ECI service delivery.

Louw’s findings (2007:65, [b]) obtained from four South African provinces indicated that ECI service delivery in the public health context did not often occur in the client’s language preference, and hospital staff was mainly used as informal interpreters when therapists could not communicate with a patient in his/her language. A shortage of qualified and trained interpreters was identified

(Louw, 2007:43, [b]), which presents an obstacle to effective ECI service delivery in public hospitals. Language differences may pose a considerable barrier to effective understanding between professionals and families (Madding, 2000:14).

28

Chapter 2

According to Lynch and Hanson (1998:78) the use of informal interpreters may influence the intervention process negatively, as these interpreters may not always provide accurate information. Despite the impact it may have on treatment, informal interpreters could still be of value to speech-language therapists who have no other means of communicating with their clients.

Madding (2000:14) states that not all speech-language therapists may become bilingual, but many can become culturally competent and linguistically aware and can locate, train and have confidence in using an interpreter. This aspect is part of the undergraduate training for speech-language therapists in South African tertiary institutions, which is positive. It is also encouraging to see that most hospitals have interpreters to assist therapists, although they are not formally trained. Louw (2007:43, [b]) found that 11% of the respondents in her study worked with trained interpreters at their hospitals. Since the multilingual nature of the South African population creates barriers to service delivery, it necessitates different approaches to intervention. Speech-language therapists are therefore obligated to become actively involved in designing programmes adapted to the multilingual needs of this country, in order to render effective and sensitive ECI services.

Early mother-infant-communication provides the foundation for evolving communication skills (Rossetti, 2001:214). Prelinguistic components of communication involve interaction, attachment, play, pragmatics and gesture, which all play an important role in the development of age-appropriate communication (Rossetti, 2001:215). Although these prelinguistic aspects are not yet bound to a specific language, different cultures possess different ways of stimulating these areas. Chan (1998:299) states that in certain Asian cultures, mother-infant-interaction is characterized by close physical contact and not necessarily by vocal stimulation. Lynch and Hanson (1998:70) state that eye contact and facial expression have different interpretations among different cultures. Body language and gestures are also used for different reasons by

29

Chapter 2 different cultures (Lynch & Hanson, 1998:72). This poses an obstacle for speech-language therapists working in the public health context.

Many South African speech-language therapists in hospital settings have shown enthusiasm by compiling and translating their own tools from literature, but this has not necessarily been published. While it is clear that speech-language therapists are aware of the needs in this context, their creativity needs to be harnessed in terms of research participation, in order to provide services that are evidence-based. Robin (1999:194) stated that speech-language therapists need to be creative and in this creativity develop new experiments and clinical procedures. Without controlled studies of treatment, we cannot know if what is being done actually works and whether some unrelated factor has been the cause of the change observed (Robin, 1999:194). Speech-language therapists who work with children are encouraged to adopt evidence-based practice for clinical decision-making (Johnson, 2006:20).

South Africa’s limited number of practicing speech-language therapists in the public health sector is a major obstacle in the delivery of ECI services. The shortage of speech-language therapists who can provide ECI and initiate prevention campaigns (Fair & Louw, 1999:16; Popich, Louw & Eloff, 2006:677) and the shortage of therapists in the public hospital context result in large caseloads. ASHA (2008) states that early intervention services need to be culturally and linguistically responsive, readily accessible and promote children’s participation in their natural environments, in order to ensure that children achieve maximum potential. It is encouraging that therapists in Louw’s study

(2007:58, [b]) are attempting to address the challenges they face in their working context. This indicates that speech-language therapists are committed to providing better services even though there are few of them in the public health service.

30

Chapter 2

Another challenge to ECI in South Africa is a dearth of apparatus and materials for the assessment and treatment of high risk and at-risk infants. Louw’s findings

(2007:62, [b]) indicate that 93% of community service speech-language therapists employed in Mpumalanga, Western Cape, Kwazulu-Natal and

Gauteng in the public health sector expressed the need for more culturally and language-appropriate materials specifically designed to address the unique needs of the South African community. Louw (2007:53, [b]) also determined that few therapists have access to a complete paediatric audiology test battery, which confirms the findings of Kritzinger et al. (1995:7) that there are limited diagnostic tools developed from a speech-language pathology and audiology perspective for neonatal assessment and management.

Therapists have expressed a need to have more appropriate tools and there is sufficient eagerness among speech-language therapists to develop tools. This is clear from unpublished attempts at compiling materials from literature. Therefore the South African context has the potential to overcome the barriers posed to

ECI and to address the challenges successfully, provided that this potential is developed.

Swanepoel (2004:16) states that South Africa is unique due to the combination of first world benchmarks within a third world country. This creates exciting research possibilities for the development of different and innovative strategies so as to effectively reach the high risk population of South Africa. While international literature provides an important framework for early intervention, speech-language therapists providing services in the developing context in South

Africa need to be creative and critical when providing intervention (Fair and

Louw, 1999:17). The importance of compiling and developing contextually appropriate instruments and tools for use in this context is therefore restated.

Previously mentioned barriers and challenges may negatively influence ECI services in South African public hospitals. Therefore speech-language therapists

31

Chapter 2 need to be equipped to provide services to the unique high risk population requiring ECI. In the local context infants and young children requiring ECI display an increased prevalence of risk conditions and are therefore different from those in developed countries (Kritzinger, 2000:13). An understanding of the high risk population in South Africa is essential in order to conduct best practice and improve the effectiveness of ECI.

2.2.3 The population requiring developmental care

The South African context determines the characteristics of the high risk population receiving ECI services in neonatal nurseries. Rossetti (2001:2) states that it is important to understand the population that needs ECI in order to effectively plan and execute treatment. Certain risk conditions associated with communication disorders have a higher prevalence in South Africa than in developed countries such as low birthweight, cerebral palsy and fetal alcohol spectrum disorder (Kritzinger, 2000:13). This is of significance to speechlanguage therapists as these conditions can be related to many developmental disorders, but more specifically to communication delays and disorders

(Kritzinger, 2000:14; Rossetti, 2001:3).

In South Africa, poverty is a characteristic of the majority of the neonatal population requiring ECI. According to Ebersöhn and Eloff (2002:78) approximately half of South Africa’s 38,8 million population is children, of which

61% live in poverty. Poverty in itself may not be the cause of developmental problems, but conditions associated with poverty in families such as malnutrition, inadequate prenatal care, exposure to infectious diseases and toxicants in utero, unsafe living conditions, living with parents who are addicted to alcohol or drugs and inadequate educational opportunities are all common in poverty circumstances (Thompson, 1992:7). These conditions are high risk factors for health, development, education, emotional and behavioural outcomes in children and place a child at increased risk for a communication development delay

32

Chapter 2

(Rossetti, 2001:6). According to Lequerica (1997:298) early intervention services to low income families must be accessible, community-based, comprehensive and holistic, and need to be provided in a team in order to combat these risk factors. Poverty often results in poor pre-, peri- and post-natal care, which may contribute to the higher prevalence of other risk factors such as low birthweight, cleft lip and palate, cerebral palsy and sensorineural hearing loss (Popich, Louw & Eloff, 2007:65).

It has been documented that 50 percent of women in Sub-Saharan Africa give birth before age 20 (Department of Health, 1998). Adolescent mothers are more likely to have low birthweight premature infants, despite adequate pre-natal care

(Rossetti, 2001:25). According to Rossetti (2001:28) teenage mothers also have a lower educational level, implying that maternal involvement may be lower than with adult mothers and therefore infants born to teenage mothers have an increased risk of developmental delay. The high levels of poverty in South Africa highlight the importance of ECI to ameliorate the negative impact of poverty on child development.

Low birthweight and prematurity are often associated with lower socio-economic groups (Rossetti, 2001:19) emphasising the need for comprehensive ECI services in the public health context. According to Pattinson (2003:62) the low birthweight rate in South Africa is two to three times higher than in developed countries. Premature and/or low birthweight neonates present with risks for social, cognitive, motor and behavioural disorders and also display an increased risk for communication disorders, therefore requiring ECI services (Rossetti,

2001:21). Studies have found major developmental disabilities including cerebral palsy, visual impairment, and hearing impairment in about one quarter of children with a birthweight less than 1000 g (Rais-Bahrami et al., 2002:99).

This necessitates effective ECI services and the involvement of a speechlanguage therapist in the neonatal care team.

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Chapter 2

The incidence of cerebral palsy in South Africa is estimated to be higher than in developed countries (Kritzinger, 2000:13). Cerebral palsy is a group of disorders that may affect movement, posture, sensation, cognition, communication, perception and/or behaviour and is attributed to a non-progressive disturbance that occurred in the developing brain (Rosenbaum et al., 2005:572). A study conducted in a rural part of Kwazulu-Natal suggested that the prevalence of cerebral palsy may be as high as 10 per 1000 (Couper, 2002:549). Cooper and

Sandler (1997:541) studied the outcomes of 113 very low birthweight infants in

South Africa and found that infants weighing below 1000g had a 24% survival rate which could be due to poorly developed intensive care facilities, frequent intra-uterine growth retardation and poor socioeconomic conditions. They also determined that ten percent of the infants in their study developed cerebral palsy

(Cooper & Sandler, 1997:542). ECI services in the NICU are therefore essential in order to plan and execute follow-up services to monitor these infants’ development from as early as possible to minimise the effects of possible communication disorders.

Another condition which characterises the high risk neonatal population in South

Africa is fetal alcohol spectrum disorder (FASD) and prenatal drug exposure.

FASD is an established risk factor for a developmental delay or disorder and is often present in the population admitted to the NICU (Billeaud & Broussard,

2003:90). Alcohol is a neurobehavioural teratogen that interferes with normal fetal growth and development, but even more important, it significantly compromises the central nervous system leading to a range of problems

(Carmichael Olsen, Jirikowic, Kartin & Astley, 2007:173). Prenatal exposure to drugs or alcohol is associated with complex physical, developmental and behavioural problems, including moderate mental retardation, organ damage, growth problems, behavioural abnormalities such as hyperactivity, concentration problems, language problems and poorly developed social skills (Fetal Alcohol

Research Initiative; Rossetti, 2001:28).

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Chapter 2

In South Africa the prevalence rates of FASD are in excess of between 30 and

50 times the rates of previously studied children in developed communities (Fetal

Alcohol Research Initiative). A study conducted in the Northern Cape Province demonstrated a prevalence of 12,2% of school entry children, which is reported to be the highest frequency yet reported in one population anywhere in the world

(Fetal Alcohol Syndrome Information). This consequently increases the number of children who may present with developmental disorders. The fact that FASD is a preventable disorder necessitates that speech-language therapists fulfil a health promotion and prevention role. According to ASHA (2005:11) the provision of public education and advocacy in order to prevent communication delays and disorders is an important function of the speech-language therapist involved in ECI.

The pandemic of HIV and AIDS in South Africa has major implications for ECI service delivery. South Africa is one of the countries with the highest number of children living with HIV and AIDS (Swanepoel, 2004:15). According to Pattinson

(2003:63) a pregnant woman infected with HIV has a twice greater risk of preterm labour. This could indicate an increase of premature infants in South

African public hospitals, which increases these infants’ risk status.

Children with paediatric HIV and AIDS may show delays in the acquisition of developmental milestones, poor receptive and expressive language, articulation problems, dysarthria, dysphagia as well as fine and gross motor delays (Larsen,

1998:89; Davis-McFarland, 2000:27). According to Larsen (1998:72) various otologic manifestations are associated with HIV. Eustachian tube dysfunction is more prevalent among this population due to the greater risk of recurrent viral opportunistic infections, adenoidal hypertrophy, nasopharyngeal masses or viralinduced allergies. This results in a higher prevalence of serous otitis media, which then contributes to speech and language delays (Larsen, 1998:72; Staley,

2004:11). Otitis media is also a common opportunistic infection among children who are HIV positive and, in addition, the medications used to treat otitis media

35

Chapter 2 may compromise hearing further due to ototoxicity (Davis-McFarland, 2000:24).

Oral pathologies are also common among the paediatric population infected by

HIV (Screen & Lee-Wilkerson, 2007). According to Lowenthal (1997:193) this population may also present with neurological impairments, motor impairments, sensory problems such as blindness and deafness as well as cognitive involvement. HIV and AIDS in children most frequently causes neurological sequelae (Screen & Lee-Wilkerson, 2007). Studies of HIV-infected children indicate that 78% - 90% present with neurodevelopmental abnormalities such as mental retardation, cerebral palsy and degrees of developmental delay (Cohen,

Grosz, Ayoob & Schoen, 1997:195).

According to Bam, Kritzinger and Louw (2003:36) an important difference between the local paediatric HIV and AIDS population and those described in literature is that the majority of infants infected with HIV and AIDS in South Africa are not cared for by their parents. This adds an additional risk for communication delay due to non-optimal caregiver-child-interaction in care centres. It is recommended that infants infected with HIV be assessed at two months and then again every six months in order to monitor and identify any neurodevelopmental delays and regression (Rossetti, 2001:33). This reiterates the importance of the involvement of the speech-language therapist in the followup and intervention process of this population.

This high risk neonatal population in South Africa requires a team approach in the neonatal nursery due to the complexities involved in their treatment.

2.2.4 The team involved in neonatal care services in public hospitals

Each team member is important to optimise care for infants admitted to the

NICU, and each member works in conjunction with the other members of the staff to contribute unique expertise (Billeaud & Broussard, 2003:92). These team members include any of several professional disciplines, including occupational,

36

Chapter 2 speech and physical therapy, education, social work, psychology, medicine or nursing, and regardless of their primary discipline, developmental care can be implemented with a basic educational and clinical background (Rossetti,

2001:174). Table 2.2 summarizes the ideal NICU team members. Each discipline has a unique role, but all have the responsibility of enhancing the infant’s health and development through promising practices of developmental care. The latter has been proven to have several benefits such as decreased hospital stay, decreased medical complications and increased behavioural and motor scores upon assessment (Goldberg-Hamblin et al., 2007:165).

A team as illustrated in Table 2.2 is recommended as best practice. However, this standard is difficult to achieve in developing contexts such as South Africa due to e.g. financial constraints and lack of staff. Furthermore not all public hospitals have NICUs and full teams as described in Table 2.2, as such nurseries are usually located at tertiary or academic hospitals due to the costs involved (Billeaud & Broussard, 2003:86).

37

Chapter 2

Table 2.2: Team members involved in neonatal developmental care and their roles

Profession

Physician

Neonatal nurse

Speech-language therapist specialising in

ECI

Paediatric audiologist

Occupational therapist

Physiotherapist

Dietician/nutritionist

Educational psychologist

Role in neonatal nurseries

- Specialised medical and/or surgical treatment of preterm and/or low birthweight infants.

- Supporting developmental care.

Sources

Billeaud & Broussard (2003)

Neonatology on the Web (2007)

- Executing specific nursing care plan for assigned infants.

- Implementation of developmental care such as cluster care, positioning, KMC.

- Systematic evaluation of infants and preparation of documentation.

- Safe and responsible use of technical equipment in neonatal nurseries.

- Assisting parents to establish relationship with infant.

- Communication evaluation and intervention.

- Feeding and swallowing evaluation and intervention.

- Parent/caregiver training and education and counselling.

- Staff and team education and collaboration.

- Supporting developmental care strategies.

Billeaud & Broussard (2003)

Neonatology on the Web (2007)

Klaus & Fanaroff (2001)

ASHA (2005)

- Screening and assessment of hearing.

- Counselling and guidance regarding intervention and follow-up services for infants with hearing loss.

- Reduction of environmental noise and implementing noise prevention programmes.

- Educating parents regarding positioning, infant development and infant states.

- Splinting

- Monitoring of motor development.

- Developmentally appropriate care such as promoting self-regulating strategies.

- Chest physiotherapy for treatment of respiratory problems

- Monitoring of gross motor development.

- Promoting sensori-motor development in the preterm infant.

Billeaud & Broussard (2003)

Billeaud & Broussard (2003)

Neonatology on the Web (2007)

Carretto, Topolski, Linkous, Lowman

& Murphy (2000)

Limperopoulos & Majnemer (2002)

Billeaud & Broussard (2003)

Neonatology on the Web (2007)

Limperopoulos & Majnemer (2002)

- Educating parents regarding infant development. Mahoney & Cohen (2005)

Improving nutrition and growth rate of the preterm and low birthweight infant. Billeaud & Broussard (2003)

Neonatology on the Web (2007)

Fenton, Geggie, Warners & Tough

(2000)

Guldenpfennig (2000) Devising preventative strategies and providing parent guidance and counselling in order to better equip parents and caregivers to deal with trauma and stress related to their infant being admitted to a neonatal care ward.

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Chapter 2

2.2.5 Programmes and services in neonatal care in South Africa

In South Africa different programmes and services are applied in the public health context in order to provide more encompassing services to high risk neonates. A literature review identified a selection of these programmes and services and they are summarised in Table 2.3. The programmes and services are grouped together according to their application. Certain programmes are implemented nationally while others were developed as part of various research projects and are thus not yet widely applied.

39

Chapter 2

Table 2.3: A selection of programmes and services in the public health sector for the neonatal population in

South Africa

National/ specific site

National

Specific site

Programme/Service

Perinatal Problem Identification Programme (PPIP)

Baby Friendly Hospital Initiative (BFHI)

Profession(s)

Neonatology

Human nutrition

Prevention of Mother to Child Transmission (PMTCT)

Neonatology

Human nutrition

Pretoria Pasteurisation Project (PPP)

Donor Breast Milk Banking

Kangaroo mother care (KMC)

Developmental care (positioning)

ECI programme for parents in KMC

Developmentally appropriate communication intervention programme in the NICU

Guldenpfennig early intervention programme for parents of low birthweight premature babies.

Neonatology

Human nutrition

Human Nutrition

Neonatology

Nursing

Nursing

Speech-language pathology

Speech-language pathology

Educational psychology

Population

All neonates

All neonates

All neonates exposed to HIV

All neonates exposed to HIV

High risk neonates

All neonates but implementation with full term infants is limited

High risk neonates

High risk neonates

High risk neonates

High risk neonates

Sources

South African Medical Research

Council (2007)

Pattinson (2003)

Department of Health (2007)

Department of Health (1999)

UNICEF (2007)

Sherman et al. (2004)

Department of Health (2007)

Department of Health (2000)

South African Medical Research

Council (2007)

Jeffery & Mercer (2000)

South African Breast Milk Reserve

(2007)

South African Medical Research

Council (2007)

Pattinson, Bergh, Malan &

Prinsloo (2006).

Dippenaar, Joubert & Brussow

Maryn (2006)

Hann et al. (1999)

Hennessy (2006)

Kritzinger, Van Rooyen & Owen

(2006)

McInroy & Kritzinger (2005)

Guldenpfennig (2000)

40

Chapter 2

Table 2.3 displays a selection of the current programmes and services being rendered by specific early intervention team members. It highlights the need for the development and implementation of neonatal communication programmes such as those developed by Kritzinger et al. (2006) and McInroy & Kritzinger

(2005:25) to effectively reach the infants and families requiring neonatal communication intervention.

A nationally applied programme, the Perinatal Problem Identification Programme

(PPIP), is a computer-based perinatal care audit programme that has been in use for approximately five years and that aims to collect data for ongoing research on peri-natal mortality (Pattinson et al., 2006:1). Institutions that use

PPIP submit data, which then is amalgamated and analyzed together with the data from the National Department of Health. It is then sent back to the original sites in reports that are named ‘Saving Babies’ (Pattinson et al., 2006:1). The

PPIP is beneficial as it has supported countrywide research in South African public health sites. According to Pattinson (2003:58) the PPIP was utilised in identifying avoidable factors and missed opportunities in preventing peri-natal death in South Africa. By using PPIP Pattinson et al. (2006:4) established that

KMC reduced neonatal mortality of immature infants. Clearly, neonatologists in

South Africa have contributed greatly to perinatal care in the local context through their continued efforts to be the driving force of the most important project to reduce perinatal mortality in South Africa.

Another nationally implemented initiative in public health is to prevent the transmission of HIV from mothers to their infants referred to as Prevention of

Mother-to-child Transmission (PMTCT). As mother-to-child transmission is the overwhelming source of HIV infection in young children, certain prevention methods have been devised by the South African government (Department of

Health, 2000). According to Sherman et al. (2004:289) PMTCT includes voluntary counselling and testing, administration of Nevirapine to mother and child, provision of free milk formula for the first six months and follow-up for

41

Chapter 2 infants on prophylactic treatment from six weeks until 12 months of age when their HIV status is determined. It has been found to be highly effective in reducing the mother-to-child transmission rate of HIV (Sherman et al., 2004:289).

Coutsoudis et al. (2001:385) report that infants who are exclusively breastfed for three months or more had no excess risk of HIV infection over six months than those who were never breastfed. This may influence policies on feeding options available to HIV-infected mothers in developing communities (Coutsoudis et al.,

2001:379). It is clear that the neonatologists and paediatricians involved in the neonatal population of South Africa are implementing extensive preventative services. Speech-language therapists can assist in this prevention drive and provide accurate information as well as intervention to parents and caregivers by being informed about current feeding policies in the public health sector.

A further nationally implemented strategy for all infants in the public health sector that was introduced in South Africa in 1994, is the Baby Friendly Hospital

Initiative (BFHI). The BFHI was propagated by UNICEF and the WHO and aims to enhance quality of life of all mothers and babies while encouraging breastfeeding as best nutrition for infants instead of formula milk and so preventing diseases such as diarrhoea (Department of Health, 2007). A ‘babyfriendly’ facility is one that does not accept free or low-cost breast milk substitutes, feeding bottles, teats or pacifiers, and has implemented ten specific steps to support successful breastfeeding (UNICEF, 2007). According to the

Department of Health (1999) the BFHI has been associated with a reduced infant mortality rate and cost-efficiency for hospitals. Training courses for health workers and assessments at maternal facilities are conducted by team members from nutrition and nursing (Department of Health, 1999).

Regarding the high risk neonatal population in neonatal nurseries, BFHI poses a dilemma for speech-language therapists since an important function of the speech-language therapist in this setting is to promote oral sensori-motor function including non-nutritive-sucking in infants who are tube-fed. Oral

42

Chapter 2 stimulation using non-nutritive-sucking via a pacifier has been revealed by various studies as being a useful calming technique during invasive procedures, as well as shortening hospital stay, improving state regulation, facilitating oral feeding and shortening transitions from tube to oral feeding (Arvedson &

Brodsky, 1993:345; Rossetti, 2001:190). In working with the high risk neonatal population, speech-language therapists who are familiar with the BFHI policy may implement different strategies for oral sensori-motor stimulation, such as using the mother’s finger, rather than using a pacifier which is not allowed under

BFHI policy.

A valuable service provided to the infant population and their mothers is the

Pretoria Pasteurisation Project (PPP). Since HIV and AIDS can be transmitted by breastfeeding, a simple and inexpensive method has been devised to pasteurise expressed breast milk in a domestic setting referred to as Pretoria

Pasteurisation in order to inactivate the virus by heating the milk (Jeffery &

Mercer, 2000:219). According to Coutsoudis et al. (2001:380) the risks of not breastfeeding are great among disadvantaged communities. Pretoria

Pasteurization Project has proven that the nutritional value of human milk is maintained while inactivating HIV, and is of value to women who do not have facilities for making up bottle feeds (South African Medical Research Council,

2007). The benefits of breastfeeding are widely recognised (Coutsoudis et al.,

2001:380). The PPP is aimed at all infants who have been exposed to HIV, but has specific value for low birthweight and pre-term infants, as the benefits of breast milk are widely recognised and it is viewed as superior nutrition for infants

(Coutsoudis et al., 2001:380; South African Breast Milk Reserve, 2007). Donor

human milk banking is another service implemented nationally to provide infants with donor breast milk to improve their health when their own mothers can not provide them with their own breast milk (South African Breast Milk Reserve,

2007). Although breast milk has been shown to reduce the risk of necrotizing enterocolitis in preterm infants when compared with formula, the role of donor

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Chapter 2 breast milk in current neonatal practice, specifically for preterm infants, remains to be established and further evidence is deemed necessary (Modi, 2006:1134).

Hospitals countrywide are attempting to implement kangaroo mother care (KMC) in neonatal nurseries. KMC is a caring method for immature neonates that was introduced in South Africa in the early 1990s, whereby the mother holds the infant on her chest (skin-to-skin contact) and feeds the infant breast milk on demand (Pattinson et al., 2006:1). KMC is an important nursing intervention in

South Africa as it has been proven to have many benefits for pre-term infants, such as reduced neonatal mortality and improved health, enhanced opportunity for mother-infant-attachment as well as cost-efficiency that benefits the health system (Hann et al., 1999:37; Pattinson et al., 2006:3). Furthermore it has been determined that KMC can safely be rendered at any primary health care setting in South Africa (Dippenaar et al., 2006:16b). Apart from medical research, research has also been conducted within the field of speech-language pathology and KMC such as Kritzinger, Van Rooyen and Owen (2006). It was found that an ECI training programme for mothers adds value to the evidence-based practice of KMC (Kritzinger, 2007). According to Rossetti (2001:1) many studies show that communication skills are the most prominent feature of developmental delay and many studies have pointed to communication delay in low birthweight infants. Speech-language therapists must therefore intervene as early as possible to minimise communication delay.

Hennessy (2006:16) implemented a developmental care programme in the NICU of a tertiary hospital in Gauteng, South Africa and found that many factors influence the implementation of developmental care, such as staff’s resistance to change, negative attitudes from team members, a lack of knowledge and training about developmental care, financial restraints and unfavourable working conditions. As part of the programme Hennessy (2006:208) compiled an intervention plan as well as guidelines for the implementation of developmental care in a public hospital’s NICU in South Africa. This led to an improvement of

44

Chapter 2 the working environment of the team involved in this specific site, an increase in the staff’s knowledge and skills, and an improvement of their morale and job satisfaction (Hennessy, 2006:208). This research project in developmental care confirms international literature findings and recommendations regarding the implementation of developmental care in an NICU. According to ASHA (2005:2) developmental care is a key principle for performing the specific roles of the speech-language therapist in the NICU. Therefore the speech-language therapist can gain valuable information from such a developmental care programme.

The developmentally appropriate communication intervention programme for the

NICU compiled by McInroy and Kritzinger (2005:25) is an example of how speech-language therapists may implement neonatal communication intervention in South Africa. This programme is designed on the principles of

Willemse (2003) and Rossetti (2001:184) that promote individualised care of the neonate and family-centred care that views the infant within the family context.

The aims of the programme are to protect and promote developmental progress, to avoid harmful environmental stimulation and to ensure the best possible outcomes for the infant and family (McInroy & Kritzinger, 2005:34). The programme comprises direct intervention with the neonate, parents and NICU staff and embraces all developmental care principles, but adding an early communication developmental perspective. It furthermore consists of an individualised care plan which is compiled weekly to provide parents with knowledge on the infant’s cues of contentedness and stress, as well as activities that may lower stress levels and optimise growth and development. The programme also utilises pamphlets, information brochures and handouts to provide information to the neonate’s parents regarding hearing, guidelines on handling, swaddling-bathing, caring for the high risk neonate at home, discharge criteria, the physical NICU environment, KMC and communication stimulation

(McInroy & Kritzinger, 2005:34). This programme is a valuable tool for use by speech-language therapists working in the public health context.

45

Chapter 2

Another innovative neonatal communication programme that has been successfully piloted in the public hospital context is the Early Communication

Intervention Programme for very low birthweight infants and their mothers in

KMC (Kritzinger et al., 2006). This programme was implemented in a KMC unit in a large peri-urban hospital in Pretoria and aims to establish a pattern of responsive communication interaction between the mothers and infants

(Kritzinger, 2007). According to Kritzinger (2006) this programme facilitates infants’ communication development as early as possible, by guiding mothers to use graded sensory input in a responsive interactive manner while doing kangaroo mother care. The programme recognizes language and cultural differences and allows for strategies to be used in order to be culturally sensitive, communicate effectively, demonstrate desired behaviours and allow trust and spontaneity to develop (Kritzinger, 2007). Kritzinger (2006) found that this programme provides speech-language therapists with guidelines regarding their role in the KMC unit. Evidence exists that the programme is effective, as improved mother-infant communication-interaction was found among mothers who applied the programme, compared to those who did not. This programme may therefore be used as an example for the development of further training programmes for parents in this context (Kritzinger, 2006).

The Guldenpfennig early intervention programme for parents of low birthweight

premature babies (Guldenpfennig, 2000) is another locally developed early intervention programme. It was developed from an educational psychology perspective and aims to provide parents of low birthweight infants support and counselling (Guldenpfennig, 2000:i). The programme is cost-effective and developed specifically for the South African context, but is also implemented in

Egypt, another developing context. The programme focuses on counselling and empowerment of parents as a strategy to prevent emotional, behavioural, developmental and learning problems later on in the child’s life (Guldenpfennig,

2000:179). Guldenpfennig’s research (2000) is an excellent example of how new strategies may be used to overcome known problem areas in service

46

Chapter 2 delivery in the South African context as well as other developing contexts such as Egypt.

These strategies are valuable for speech-language therapists to use in the further development and validation of tools for neonatal communication intervention in neonatal nurseries in South Africa.

2.2.6 Neonatal communication intervention: Role of the speech-language therapist

Neonatal communication intervention within the neonatal nursery is the most recent application of the concept of early communication intervention (Rossetti,

2001:171). According to ASHA (2005:2) the speech-language therapist’s role in the NICU is comprehensive and dynamic and may vary with the specific characteristics and needs of the infants and families being served. This is captured in Figure 2.2.

47

Chapter 2

Figure 2.2 Roles and responsibilities of the speech-language therapist in the NICU (ASHA, 2005; Rossetti, 2001)

ASHA (2005:12) furthermore states that speech-language therapists have the responsibility to fulfil these roles using practices that are based on research, family-centred, culturally and linguistically appropriate, developmentally appropriate and collaborative. The execution of these responsibilities and functions is dependant upon a well-developed theoretical as well as clinical foundation.

48

Chapter 2

A theoretical underpinning is vital as speech-language therapists are required to prove that the services they are currently providing in ECI are effective (Louw,

2007 [a]). Bernstein-Ratner (2006:257) states that in order for practice to be effective, information must be updated constantly and the clinician must consistently seek out new information to improve therapeutic effectiveness.

According to ASHA (2005:12) speech-language therapists are responsible to provide services that are research-based. Evidence-based practice is a framework for clinical decision-making that entails the integration of best research evidence with clinical expertise and patient values (Johnson, 2006:20).

According to Louw (2007 [a]) basing clinical decisions on scientific research is fundamental to ethical practice in ECI.

In order to fulfil the roles and responsibilities in neonatal communication intervention demonstrated in Figure 2.2 effectively, the speech-language therapist requires certain tools. ASHA (2005:6) states that instrumental methods for evaluating swallowing function such as video-fluoroscopic swallow study answer specific diagnostic questions and guide management decisions, and will therefore aid in formulating the speech-language therapist’s recommendations.

Examples of low technology tools are pictorial depictions, written handouts and videos when therapists provide guidance to parents and caregivers. Gani

(2004:61) and Strasheim (2004:48) found materials based on The Hanen

Programme (Pepper & Weitzman, 2004) to be useful in training a group of caregivers in communication stimulation in a care centre and a positive effect on caregiver-child-interaction patterns was determined. According to McConkey

(1995:80) video material is a convenient tool when training parents, as this provides them with a visual representation and it is repeatable. Tools are therefore also required when providing ECI services to parents as they assist the speech-language therapists in fulfilling their roles as illustrated in Figure 2.2.

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Chapter 2

2.2.7 Neonatal communication intervention tools in South Africa

The early communication intervention process consists of a series of procedures.

According to Sandall (1997:211) assessment and intervention are both early intervention services and are intertwined and interdependent. Assessment is crucial to the effectiveness of intervention programmes (Sandall, 1997:211). No clear line exists between assessment and intervention as both are part of the intervention process. Portions of each are found in the other and this should be an ongoing process (Owens, 1999:58). Within neonatal communication intervention speech-language therapists are involved in assessment of readiness for feeding, swallowing function, developmental aspects such as communication, sensory, motor, state and physiological behaviours (Ziev, 1999:33).

Intervention programmes serve to identify at-risk infants as early as possible

(Moodley et al., 2000:25). According to Kritzinger (2006) applying neonatal communication intervention programmes during the peri-natal period, such as a training programme for low birthweight neonates and their mothers in a KMC ward, offers unique opportunities to intervene early as the mothers are available during this time.

Popich et al. (2007:68) found that a need exists for instruments and strategies that are specifically designed to address the communities’ needs in the unique context of South Africa. Consequently it is critical to review the availability of neonatal communication intervention tools in the South African context in order to justify, to a certain extent, the need to develop a contextually appropriate tool.

An in-depth literature review led to the compilation of a list of tools that are being used in the South African context. Only tools that are formally documented were included. Table 2.4 illustrates tools for the assessment of the high risk neonate’s

communication and feeding abilities. Each tool is summarised according to its aim and whether it was developed internationally or for the local population. It is

50

Chapter 2 also necessary to distinguish between assessment tools and intervention programmes or tools and therefore this information is displayed separately. A selection of neonatal communication intervention programmes developed for the local context is reflected in Table 2.5 and is summarised according to its aim and whether it is published or not. This information serves to point out that although not all research attempts are published, many researchers and clinicians are attempting to fulfil a need on a small scale. This serves to illustrate that many speech-language therapists in South Africa have the interest and creativity to produce adapted materials even though these tools’ use and clinical applicability may not have been formally researched yet.

51

Chapter 2

Table 2.4: A Selection of tools available for assessment of the high risk neonate’s communication and feeding abilities

Name of tool

Observation of Communicative Intent (OCI)

Oral-Motor/Feeding Rating Scale

Genetic Screening Checklist

Neonatal Communication Assessment Guide

Data collection protocol for high risk neonates

Clinical Feeding Evaluation of the Infant

Neonatal Communication Assessment Instrument

CHRIB Risk Assessment

Feeding Evaluation Form for At-Risk Infants

(FEFARI)

Aim

Mother-child-communicationinteraction

Reference

Klein & Briggs (1987)

Kritzinger et al. (2006)

Developed internationally or locally

Internationally and adapted for neonatal use by

Kritzinger et al. (2006)

Internationally Feeding

Visual screening of genetic anomalies

Developmental delays that may influence communication

Communication development and feeding

Feeding

Jelm (1990)

Kritzinger & Louw (1998) Locally

Swanepoel (2000)

McInroy (2007)

Kritzinger (1996)

Locally

Locally

Locally

Communication development and risk factors

Risk factors

Kritzinger & Louw (2003) Locally

Feeding

Kritzinger (1994) revised

(2003)

Uys (2000)

Locally

Locally

Locally

Developmental Care Plan (Medforum Hospital)

Neonate’s development including sleep-awake states, behaviour and environment.

Compiled from Kritzinger (2007) and McInroy (2007).

Willemse (2003)

52

Chapter 2

Table 2.5: Locally developed neonatal communication intervention tools

Programme

Developmentally appropriate communication intervention programme in the NICU

Aim & content

- Promote developmental progress

- Avoid harmful environmental stimuli

- Ensure best possible outcomes for neonate and family

- Training of nurses in developmentally appropriate care

Reference

McInroy & Kritzinger (2005)

Van Jaarsveld (2004)

Verpleegkundiges se persepsies van ontwikkelingstoepaslike sorg voor en na opleiding

Verpleegkundiges se kommunikasiestimulasie van hoërisikobabas in die neonatale sorgeenheid

Kraamwinkel & Louw (1998)

KMC Training Programme

An ECI training programme for low birthweight infants and their mothers

- Providing nurses with basic information and guidelines regarding communication stimulation with high risk infants in the NICU as well as associated behavioural responses

- Providing training to nurses regarding KMC in order to facilitate effective application of this technique as a developmental care strategy

- Providing training to mothers of high risk infants in KMC

Payne (2000)

Kritzinger, Van Rooyen & Owen

(2006)

Published or unpublished

Published

Unpublished

Published

Unpublished

Unpublished

53

Chapter 2

Tables 2.4 and 2.5 demonstrate that clinical needs have been identified by local researchers and clinicians and that small-scale research projects have been conducted, but have not necessarily been published or disseminated amongst professional peers. This clearly limits their use and application, because evidence-based practice is the use of high quality research evidence that is integrated with client-specific goals, and clinical experience that is used to shape clinical decision-making (Louw, 2007 [a]). These speech-language therapists attempt to meet the needs of the local context by developing contextually relevant tools and therefore their contribution should not be ignored. Bernstein-

Ratner (2006:262) states “no evidence that something works YET is not the

same as evidence that it does not work”. It is important to note that these tools may not yet have high quality evidence of effectiveness and therefore the application is limited and should be researched further.

Best practice in developmental care in neonatal nurseries needs to be encouraged and facilitated, which necessitates the development of appropriate tools for the local context. According to ASHA (2005:2) speech-language pathologists need to develop culturally appropriate programs that meet the needs of ethnically and linguistically diverse families. Therefore culturally and contextually appropriate tools and programmes for neonatal communication intervention need to be developed for the South African context, in order to serve the unique high risk population in South Africa in an effective and ethical manner.

The unique contextual reality of South Africa should be taken into account when neonatal communication tools are developed. These tools should be based upon an expressed need within this context and should be contextually relevant.

Therefore, if they are based on western models of communication stimulation, these tools should be adapted appropriately for the South African context. Due to the diversity of cultural groups in South Africa, overseas tools and programmes cannot merely be translated (Visser, 2005:57). The interdependent relationship between culture and language must be taken into consideration

54

Chapter 2 during cross-cultural service delivery, otherwise the tool will still not be suitable even though it was translated (Pakendorf, 1998:2).

It may also be beneficial to consider contextual adaptations in order to bridge other challenges such as limited literacy among caregivers. According to Louw et al. (2006:53) literacy issues may be overcome by using visual sources such as pictorial depictions as well as demonstrations, as written materials are not necessarily viewed to be important, especially by individuals with low literacy levels. Strasheim (2004:15) compiled and applied a training programme based on the principles of The Hanen Programme (Pepper & Weitzman, 2004) in communication stimulation for caregivers of infants and young children between birth and three years with HIV and AIDS in a local care centre. Findings showed that, even though the caregivers felt positive about the training, they indicated a need for training material such as videos and posters to be culturally appropriate and relevant to their working context (Strasheim, 2004:42). These findings confirm the need for appropriate early communication intervention tools and programmes adapted for the culturally and linguistically diverse population in

South Africa.

By using the general considerations of communication-based intervention described by Rossetti (2001:182) and adapting it to the linguistic, cultural and contextual needs of the South African high risk neonatal population, parent and caregiver guidance in communication stimulation may be readily and efficiently facilitated, as seen in the programme developed by Kritzinger et al. (2006).

Furthermore, by using internationally published intervention programmes in compiling or developing a locally relevant tool, the dearth of materials and programmes may be overcome while international trends in early intervention are still followed, provided that these programmes are researched to confirm their effectiveness.

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Chapter 2

2.3 CONCLUSION

Best practice in ECI is to provide services as early as possible to increase the benefits to both the infants and the families (Rossetti, 2001:270). Therefore speech-language therapists have an integral part to play in the neonatal nurseries, as this being the context for the earliest intervention (Rossetti,

2001:171). ECI is of utmost importance in a country such as South Africa, where there is an increased prevalence of infants who are at risk for disabilities and where the majority of these infants live in poverty (Kritzinger, 2000:9).

The literature review clearly indicated that speech-language therapists fulfil an essential role in the neonatal nursery and are an integral part of the team involved with the high risk neonatal population. From an asset-based perspective it appears that the South African population receiving services in neonatal nurseries have unique characteristics, which provide speech-language therapists with ample opportunity to intervene, providing that intervention is well-timed in the neonatal nursery context. Furthermore it is apparent that speech-language therapists in South Africa are involved in and committed to ECI, but have specific needs regarding their working conditions, experience, interpreters and tools.

Local speech-language therapists are dedicated to overcome barriers in their working context and have enthusiasm to improve the services they render to this population. This is clear from undergraduate research projects as well as clinicians’ attempts to translate and compile materials from current ECI literature that have not yet been published or researched further. In order to propose a solution to address the shortage of tools in the public health context, this research aims to establish how widely speech-language therapists are utilising existing tools. Thereafter a neonatal communication intervention tool will be developed to be used by speech-language therapists in the public hospital context.

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Chapter 2

2.4 SUMMARY

In this chapter issues relevant to the development of a neonatal communication tool were identified and described. A review of best practice in developmental care and ECI in South Africa initiated the discussion. The South African context was described according to assets thereof, as well as the barriers to service delivery in this context. Developmental care in South Africa was illustrated in terms of how it differs from the preferred practice described in literature from

USA, Britain and Canada. The characteristics of the high risk population that requires ECI services were identified and discussed. The team involved in developmental care in neonatal nurseries, as well as the services and programmes sustained in the public health context, were described. The dilemma regarding the availability of appropriate tools and programmes for neonatal communication intervention in South Africa was highlighted. Aspects to be considered in the development of a neonatal communication intervention tool were identified and described. It was argued that the development of a contextually appropriate tool might be a possible solution for the shortage of tools and programmes for use in neonatal nurseries in the local context.

57

Chapter 3

CHAPTER 3

Methodology

___________________________________________________________________________________________

3.1 INTRODUCTION

Clinical and research practices are not separate entities, but are rather combined disciplines that serve a common goal (Robin, 1999:194). Research plays a critical role to determine the efficacy of a given treatment and clinicians cannot hope to evolve clinically without convincing documentation that their clinical procedures are effective (Robin, 1999:194).

South Africa has an increased prevalence of infants who are at risk for disabilities, with the majority of these infants living in poverty, as well as an increased incidence of low birthweight and premature infants among pregnant women with HIV and AIDS (Kritzinger, 2000:9; Van Rooyen, Pullen, Pattinson

& Delport, 2002:7; McInroy & Kritzinger, 2005:33). Therefore knowledge about high risk infants and their families is now more important than ever and requires the attention of all early interventionists (McInroy & Kritzinger,

2005:33).

Speech-language therapists providing ECI services to the high risk neonatal population appear to have specific needs regarding interpreters, tools and materials, their working conditions and experience. Therefore the aim of this study was to compile a locally relevant instrument/tool for use by speech-language therapists in neonatal nurseries.

The aim of this chapter is to provide a systematic and detailed description of the research process that was followed during the execution of this study.

The chapter provides information on the aims, research design, participants, materials, data-collection and analysis, which allows for duplication of the study.

58

Chapter 3

3.2 AIMS

The overall aim of this study was to compile a locally relevant neonatal communication intervention instrument/tool for use by speech-language therapists in the neonatal nurseries of public hospitals.

The following objectives were formulated in order to reach the main aim:

To describe the perceptions of speech-language therapists and audiologists providing early communication intervention (ECI) services in provincial hospitals in South Africa regarding their role in the neonatal nurseries.

To identify participants’ needs in terms of neonatal communication intervention instruments/tools.

To select and justify a specific need of the participants in terms of neonatal communication intervention instruments/tools in the public hospital context.

To compile a preliminary instrument/tool based on the selection of one of the perceived needs of the participants.

To pre-test the completed instrument/tool and make changes if necessary.

3.3 RESEARCH DESIGN

According to De Vos, Strydom, Fouché and Delport (2005:137) a research design focuses on the end product of the research, formulates a research problem as a point of departure and focuses the logic of the research. For the purpose of this study a descriptive, exploratory study within the

quantitative and qualitative frameworks of research design was selected.

Descriptive research is used to provide a detailed picture of a specific situation, relationship or social setting (De Vos et al., 2005:109). The goal of

exploratory research is to gain insight into a situation, phenomenon, community or person that is not well known (De Vos et al., 2005:109). These

59

Chapter 3 research objectives are therefore appropriate for this particular study that will explore and describe the needs of the specific population of speech-language therapists providing ECI in neonatal care nurseries of public hospitals.

A descriptive survey was deemed to be appropriate for compiling an overview of the speech-language therapists’ perceptions and needs regarding their early intervention service provision in the specific context of the neonatal nurseries in public hospitals. The study was conducted in two phases and is illustrated in Figure 3.1.

Figure 3.1: Phases of the research project

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Chapter 3

Phase 1 entailed an exploratory descriptive survey, where the researcher made use of a self-designed questionnaire to obtain the information regarding the perceptions and the needs of speech-language therapists, whereafter the data was analysed quantitatively. Phase 2 entailed the compilation and piloting of a neonatal communication intervention instrument/tool for speechlanguage therapists working in the neonatal nurseries in public hospitals. The compilation was based on a comprehensive literature review, as well as information gained from the participants in Phase 1. The compiled instrument/tool was piloted in order to validate it. The two phases will be presented separately as the results of Phase 1 determined the content of

Phase 2.

A quantitative as well as qualitative framework was selected for this research.

Quantitative research includes surveys and content analysis and is therefore appropriate for this research project as the first phase entailed a survey to investigate the perceptions of a specific population (De Vos et al., 2005:138).

According to Leedy and Ormrod (2005) qualitative research is used to answer questions about the complex nature of a phenomenon, in order to describe and understand it. The results of Phase 2 entailed the compilation of a neonatal communication intervention tool that was also described qualitatively.

3.4 RESEARCH ETHICS

Research ethics is important in order to protect the rights and safety of research subjects (Maxwell & Satake, 2006:214). The three basic ethical principles, namely autonomy, beneficence and non-maleficence, and justice

(Leedy & Ormrod, 2005:101) were applied as follows:

Autonomy: The participants were informed of what the study entailed and their voluntary participation was requested (Leedy & Ormrod, 2005:101). The researcher made use of a cover letter (see Appendix C) to describe the nature of the research and the rights of the participants, and to obtain their

61

Chapter 3 informed consent. The participants’ confidentiality was ensured in order to encourage them to express their thoughts and feelings openly (Maxwell &

Satake, 2006: 216).

Beneficence and non-maleficence: The risks involved in this study were minimal (Maxwell & Satake, 2006: 216). One of the possible risks was that the participants might be requested to provide information and share opinions about their work contexts and service delivery. As this kind of information might be confidential, it could jeopardise their employment. Confidentiality was ensured by allocating a number to every participant, in this way protecting their identity (Maxwell & Satake, 2006: 216). The researcher acted in the participants’ best interest and their rights were respected by presenting the results in a manner that would not allow others to identify specific participants.

Wherever human beings are the focus of investigation, the researcher must look closely at ethical implications of the proposed research (Leedy &

Ormrod, 2005:101). The researcher attempted to comply with the prescriptions for ethical research. The research proposal was granted ethical clearance by the Research Proposal and Ethics Committee, Faculty

Humanities, University of Pretoria and the researcher adhered to the committee’s recommendations (see Appendix A [i]). Permission to conduct the research was also obtained from the departments of health in Gauteng,

Eastern Cape, KwaZulu-Natal, Mpumalanga, Northern Cape and North West being the employers of the participants (see Appendix A [ii]).

The two phases of the research are presented separately for clarity.

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Chapter 3

3.5 PHASE 1

3.5.1 Objectives

The objectives of Phase 1 were:

To describe the perceptions of speech-language therapists and audiologists providing ECI services in provincial hospitals in South

Africa, regarding their role in the neonatal nurseries.

To identify participants’ needs in terms of neonatal communication intervention instruments/tools.

3.5.2 Sample

Neonatal communication intervention is a specialised field within the professions of speech-language therapy and audiology and therefore the population available for this study was limited. Permission for this study could only be obtained from six of the nine provinces, which further reduced the population available for the research. All the participants who met the selection criteria and who returned a questionnaire, were therefore included in the study.

3.5.2.1 Population

The population from which the participants were selected were qualified speech-language therapists and audiologists working in public hospitals in

South Africa.

3.5.2.2 Criteria for the selection of participants

The following criteria were applied in the selection of the research participants.

Occupation

Each participant had to be qualified and practicing as either a speechlanguage therapist, an audiologist or a speech-language therapist and audiologist. As an objective of this study was to investigate the roles of

63

Chapter 3 speech-language therapists and audiologists currently providing services in neonatal nurseries, it was deemed important that only qualified and

practising professionals be included in the study.

Employer

All the participants had to be employed by the provincial departments of health in South Africa. An objective of this study was to determine speechlanguage therapists/audiologists’ needs, specifically relating to their service delivery in public hospitals in South Africa. ECI services to neonates in the

South African public health sector are less comprehensive and less developed in comparison to developed countries (Kritzinger et al., 1995:7).

Therefore knowledge of the needs of early communication interventionists in the public health sector is essential in order to reflect the unique characteristics of ECI in this context and to furthermore compile a tool that is relevant for clinical use in this context.

Work experience

All the participants in this study had to provide ECI to infants in a neonatal nursery such as an NICU, neonatal high care ward or KMC ward, as this study specifically focused on the participants’ needs regarding neonatal ECI.

The early interventionist providing developmental care in the NICU requires specialised knowledge and therefore current practices directed at infants differ from those directed at older children (Rossetti, 2001:176). Not all provincial hospitals have NICUs, but many hospitals have either neonatal high care wards or KMC wards. Therefore participants providing intervention in any of the specified neonatal nurseries (NICU, neonatal high care ward or

KMC ward) were included in the study.

3.5.2.3 Selection procedures

The following procedures were applied during the selection of the research participants:

The provincial departments of health were contacted telephonically regarding the study. The relevant persons were requested permission

64

Chapter 3 to involve the speech-language therapists and audiologists in the research (see Appendix B).

They were also requested to provide statistics regarding the number of speech-language therapists and audiologists employed at the hospitals in their province, as well as each hospital’s contact details.

Written permission was obtained from six of the nine provinces namely

Gauteng, KwaZulu-Natal, Eastern Cape, Northern Cape, North West and Mpumalanga (see Appendix A [ii]). The provincial departments of health of the Free State, Western Cape and Limpopo did not respond.

The potential participants targeted for the study in the six provinces that responded, were contacted telephonically to explain the aim of the study and discuss whether they would be willing to participate in the study. The researcher also asked participants how they would prefer to receive the questionnaire (e.g. via post, e-mail or facsimile).

A cover letter and consent form (see Appendix C) and the questionnaire (see Appendix D) were sent to potential participants via facsimile or e-mail, who indicated that they were willing to participate in the study.

3.5.2.4 Description of the participants

Table 3.1 displays the number of speech-language therapists and audiologists employed in each province. This number was calculated from lists received from the provincial departments of health prior to the commencement of the study.

65

Chapter 3

Table 3.1: Number of speech-language therapists and audiologists in provincial hospitals in South Africa

Province

Number of professionals

Number questionnaires sent

KwaZulu-Natal

Gauteng

Limpopo

Mpumalanga

Western Cape

North West

Northern Cape

Free State

Eastern Cape

TOTAL

60

51

-

32

-

14

16

-

2

175

(Source: provincial departments of health, 2007)

60

51

-

32

-

14

16

-

2

175

Number questionnaires returned

11

-

2

41

11

3

-

12

-

2

%

18.3

5.8

-

37.5

-

14.2

68.7

-

100

23.4

A total of 41 out of 175 speech-language therapists and audiologists returned completed questionnaires rendering the return rate of questionnaires to be

23%. According to Leedy and Ormrod (2005:193) the average return rate for a mailed questionnaire is 50% or less and has declined in recent years. The return rate in this study was less than the adequate rate of 50% that is stipulated in the literature (Babbie, 1995: 262). This was ascribed to participants’ lack of time and large caseloads being, and in many cases due to being the only speech-language therapist or audiologist at the hospital.

The poor return rate could also be explained by the fact that few professionals provided neonatal communication intervention in their hospitals.

The responses obtained from the 41 participants are therefore not representative of speech-language therapy and audiology services in the public health sector in South Africa. Due to the fact that approval for the study the provincial departments of health of the Free State, Limpopo and

Western Cape could not be obtained in time for completion of Phase 1, those therapists did not participate in the study.

The characteristics of the participants are provided in Figure 3.2 to Figure

3.10. As one participant did not complete Section A entirely, certain figures

66

Chapter 3 represent only 40 participants. Figure 3.2 displays the participants’

professional qualifications.

49%

Speech-language therapist

Audiologist

Speech-language therapist &

Audiologist

46% 5%

Figure 3.2: Professional qualifications (n = 41)

The large number of participants qualified only as speech-language therapists, could be explained in the light of Figure 3.6. A total of 27% of the participants completed their highest qualification at the University of

Stellenbosch, that currently does not present a degree course in Audiology.

The minority of participants were qualified as audiologists only. This could be due to the fact that the questionnaire targeted service delivery in neonatal nurseries. When the questionnaire was received at the targeted hospitals, it may have been given to the speech-language therapists or dually qualified therapists to complete rather than to the audiologists. This implies that the results of the study, and the resultant tool, will reflect the needs and preferences of speech-language therapists rather than audiologists.

Figure 3.3 displays the provinces where participants are currently

employed.

67

Chapter 3

29%

25%

28%

Eastern Cape

Gauteng

KwaZulu Natal

Mpumalanga

Northern Cape

North West

8%

5%

5%

Figure 3.3: Provinces where participants are employed (n = 40)

The majority of participants were providing services in Mpumalanga (29%) and the Northern Cape (28%). A few participants were employed in Gauteng and the Eastern Cape (5%) respectively. This could be ascribed to the fact that only a few speech-language therapists and audiologists are employed in the Eastern Cape. The participants’ years of experience in the

government sector is depicted in Figure 3.4.

30

25

20

15

10

5

0

25

1 or < 1

6

2

3

2

1 1

3 5 6 7

Years of experience in the government sector

1

8

1

12

Figure 3.4: Years of experience in the government sector (n = 40)

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The majority of the participants was relatively inexperienced in this working environment. Only nine of the 41 participants (36%) had two or more years of experience. This implies that the results of this study, as well as the resulting tool, will reflect the opinions and needs of inexperienced professionals. The fact that few experienced professionals completed the questionnaire indicates that the tool will probably be more applicable to the younger, inexperienced professionals.

The participants’ highest qualifications and the universities where these

qualifications were obtained are illustrated in Figure 3.5 and 3.6.

90%

Bachelor degree

Master's degree

10%

Figure 3.5: Highest qualifications (n = 41)

Figure 3.5 illustrates that only four participants (10%) had Master’s degrees.

This is attributed to the fact that the majority of participants were newly qualified therapists who recently commenced their professional careers and had not yet completed post-graduate studies (see Figure 3.4). This implies that few participants may be skilled in the specialised area of neonatal communication intervention in the neonatal nursery.

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Chapter 3

29%

18%

8%

Pretoria

Witwatersrand

Stellenbosch

Cape Town

KwaZulu-Natal

18%

27%

Figure 3.6: Universities where highest qualifications were obtained

(n = 40)

The majority of participants obtained their highest qualifications from the

University of Pretoria (29%) and the University of Stellenbosch (26%). When compared to Figure 3.3, it is clear that the participants were not employed in the same province where they obtained their qualifications.

The contexts where participants rendered services are displayed in

Figure 3.7.

35

30

25

20

15

10

5

0

26

30

12

1

Contexts

Figure 3.7: Contexts of service provision (n = 41)

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As previously, participants indicated more than one working context. The majority of participants worked at district or regional hospitals. Many participants provided services at community clinics or health centres, indicating that the participants employed at regional or district hospitals were also rendering services at clinics in their respective communities. This is attributed to the large number of participants that were employed in their community service year at district or regional hospitals.

Figure 3.8 depicts information on the wards where ECI was provided. As before, the participants indicated more than one type of ward.

23

25

20

15

10

5

0

14

20

Ward

Figure 3.8: Wards where ECI was provided

According to Figure 3.8 most of the participants provided ECI in a neonatal high care unit while approximately half of the participants were working in a

KMC ward. Few provincial hospitals have NICUs and these specialised wards are usually located at tertiary or academic hospitals, which explain why few participants are exposed to this context (refer to Figure 3.7).

Figures 3.9 and 3.10 display information regarding number of speech-

language therapists or audiologists and trained interpreters and

assistants in the department where the participants worked.

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Chapter 3

16

14

12

10

8

6

4

2

0

15

10

5

11

1 2 3

Number of speech-language therapists or audiologists

> 3

Figure 3.9: Number of speech-language therapists or audiologists in the speech-language therapy and audiology departments (n = 41)

Figure 3.9 illustrates that 15 of the participants were the only speechlanguage therapist or audiologist employed in their department implying that they had neither supervision nor assistance. This could impact negatively on their service delivery as they probably had large caseloads to manage on their own, leading to work stress and feelings of incompetence.

According to Figure 3.10 only 10% of the participants had trained interpreters or assistants in their departments. Limited funding for posts as interpreters and assistants in the public health sector may be a possible explanation for this finding. This is problematic as language differences may impede on the relationship between the professional and family and influence the intervention process negatively (Madding, 2000:14). This challenge can be addressed by collaboration with trained interpreters in this context.

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90%

Yes

No

10%

Figure 3.10: Trained interpreters and/or assistants

In summary, the majority of participants worked at district or regional hospitals as well as community outreach clinics. They provided ECI in the neonatal high care unit and KMC unit of their hospitals. Most participants appeared to be inexperienced in providing neonatal ECI services. They may have been without supervision as most participants were the only speech-language therapist/audiologist employed at their hospital and had limited access to interpreters and assistants.

3.5.3 Materials

The following materials were used for data collection.

3.5.3.1 Cover letter

A cover letter (see Appendix C) was attached to the questionnaire, explaining the aims of the study and the importance thereof. The cover letter provided the participants with a brief description of the nature of the study, a description of what participation would involve, a list of potential risks or discomforts, a guarantee that all responses would remain confidential, a means to reach the researcher in case they needed clarity on certain questions and also ensured the participants’ anonymity (Leedy & Ormrod,

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2005:102). A request for informed consent from the participants was also included in the cover letter.

3.5.3.2 Self-designed questionnaire

A self-designed questionnaire was selected as data collection tool to conduct the survey (see Appendix D).

a) Justification for the use of a questionnaire as data-collection tool

Survey research is one of the best methods available to describe a population that is too large to observe directly (Babbie, 1995:257). A questionnaire allows the participants a high degree of freedom in the completion thereof and information can be gathered from a large number of participants within a brief period of time (De Vos et al., 2005:172). It is also a cost-efficient method to reach participants who are spread across a wide geographical area (De Vos et al., 2005:172). This made it suitable for the current study as participants were spread across six provinces in South Africa.

A questionnaire was selected in preference to structured interview schedules and focus groups, as the data-collection tool of choice for a number of reasons. Research interviewing entails recording and managing large volumes of data even after relatively brief interviews (De Vos et al., 2005:293) and as this research was intended to be a national study, the number of participants involved would make interviews time-consuming and expensive.

Focus groups are especially effective in obtaining data on perceptions regarding a defined area of interest in a short period of time (De Vos et al.,

2005:306). Focus groups would have been logistically difficult to implement as the participants were distributed countrywide.

The researcher took cognisance of the pitfalls and limitations of using questionnaires in the compilation thereof. According to De Vos et al.

(2005:172) questionnaires that have many open-ended questions that take long to complete, often have a low response rate. Some questions may also be left unanswered or wrongly interpreted as there is no fieldworker to assist

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Chapter 3 the participant (De Vos et al., 2005:173). The design reflects these considerations.

b) Aim of the questionnaire

The aim of the questionnaire was to determine the perceptions of speechlanguage therapists and audiologists regarding their role in the neonatal nurseries in the hospitals they worked in. The questionnaire also aimed to determine the speech-language therapists’ and audiologists’ needs in this context regarding clinical instruments or tools for assessment and intervention directed either at the parents or staff.

c) Design of the questionnaire

Guidelines followed in compiling the questionnaire

Published guidelines were followed in the compilation of the questionnaire, thereby enhancing the validity and reliability thereof (Leedy & Ormrod, 2005:

190). The language used in the questionnaire was simple and unambiguous, questions were short and clear instructions were provided (Leedy & Ormrod,

2005:190). A pilot study was conducted to pre-test the questionnaire (Leedy

& Ormrod, 2005:192).

Types of questions included in the questionnaire

The questionnaire was comprised of both open- and closed-ended questions.

Closed-ended questions: The following questions were closed-ended: A1 -

A9, B1 – B6, B9 – B11, C1, D1 – D3. Closed ended questions are preferable to open ended questions as they are less time-consuming to complete and make the data analysis less complex (De Vos et al., 2005:180).

Open-ended questions: The following questions were open-ended: B7 –

B8, B12, C2 – C3, D4 – D5. Although open-ended questions lengthen the time spent to complete the questionnaire, these questions will enable the researcher to obtain a better idea of the spectrum of possible responses and to explore the aspect being researched in more depth (De Vos et al.,

2005:179).

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Content of the questionnaire

The questionnaire is comprised of four sections containing a total of 27 questions. The inclusion of each section is justified in Table 3.2.

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Table 3.2: Content of the questionnaire

Section

A

Themes

Biographical data

(9 questions):

-

Profession

-

Qualifications

-

Province employed

-

Years experience

-

Number of employees in department

Justification for inclusion

The biographical data was used to interpret the data from other sections of the questionnaire.

References

De Beer (2003)

Van Rooyen (2006)

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Table 3.2: Content of the questionnaire (continued)

Section

B

Themes Justification for inclusion References

Service delivery

(11 questions):

-

ECI in the hospital

-

Task allocations

-

Contexts for ECI (NICU, neonatal high care,

KMC)

Task allocations are justified by the fact that a speech-language therapist’s high caseload is directly related to increased stress, while mentoring at work offers support and guidance (Lubinski, 2007:537). It is therefore important to identify participants’ task allocations.

Few hospitals have NICU nurseries due to costs involved in maintaining their services (Billeaud &

Broussard, 1998:86) and thus it is important to enquire

-

Functions and roles:

Assessment:

about participants’ contexts of service delivery. In

South Africa, the KMC ward is often used as a step-

Feeding, utilising video-fluoroscopic studies, communication interaction, hearing screening. down unit for neonates (Kritzinger, 2007).

Neonatal ECI services can be directed at the neonate,

Treatment directed at infant and parents:

the parents/caregiver or the staff members (Rossetti,

2001:270) and therefore the participants were asked

ASHA (2005)

De Beer (2003)

Billeaud and

Broussard (2003)

Kritzinger (2007)

Louw, Van Eede

& Louw (1998)

Lubinski (2007)

Rossetti (2001)

Ziev (1999)

Direct treatment of the infant [e.g. oral-facial stimulation], intervention for feeding problems and prevention of communication delays in the form of parent guidance, developmental care,

KMC, discharge planning and planning of followup treatment, informing parents/caregivers of about their specific functions in the neonatal nursery.

Functions and roles included in the questionnaire were compiled from Rossetti (2001:181), ASHA (2005:2) and

Ziev (1999:33).

People who are more focused on the characteristics of infant’s condition, progress and future expectations, counselling and support of their work (such as the challenges and how interesting the work is) tend to demonstrate more personal parents.

Treatment directed at staff/team members:

involvement, motivation and enthusiasm for their work

(Louw, Van Eede & Louw, 1998:538). Speech-language therapists and audiologists require work satisfaction in

Consultation with team, attendance of ward rounds with other team members, in-service training of staff/team members.

-

Work satisfaction and competency

order to excel in their professions and therefore the questionnaire should investigate participants’ perceptions of their competence and work satisfaction in the neonatal nursery.

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Table 3.2: Content of the questionnaire (continued)

Section

C

Themes Justification for inclusion References

Needs in terms of the following (3 questions):

- Service delivery:

Referrals from other professionals, screening

In the South African context speech-language therapists and audiologists are faced with a multitude of challenges in providing ECI (Fair & Louw, 1999:16). In order to fulfil their roles and responsibilities in the neonatal equipment or materials, assessment equipment or materials, treatment equipment or materials, counselling methods, team nursery, speech-language therapists and audiologists require certain equipment and tools. It is thus important to enquire about participants’ opinions of members, time management, resources, inservice training, continued professional development. improvements to future service delivery in the neonatal nursery.

-

Perceptions of culturally appropriate tools

-

Perceptions of user-friendly tools

Popich et al. (2007:68) found that a need exists for strategies that are specifically designed to address the communities’ needs in the unique context of South

Africa. Speech-language therapists working in the NICU need to provide culturally appropriate care as cultural factors shape family responses to information and intervention (ASHA, 2005:2). Therefore it is important to enquire about participants’ opinions of culturally relevant and user-friendly tools in their work context.

ASHA (2005)

De Beer (2003)

Billeaud and

Broussard

(2003)

Rossetti (2001)

Van Rooyen

(2006)

Ziev (1999)

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Table 3.2: Content of the questionnaire (continued)

Section

D

Themes Justification for inclusion References

Needs in terms of tools (4 questions):

Speech-language therapists play an integral role in facilitating communication development, appropriate

-

Assessment:

assessment of prelinguistic and socio-communicative interactions and performing developmentally appropriate feeding, mother-child interaction, NICU environment. 2005:3). It is therefore essential to establish whether participants have tools to use in this regard, as this

-

Treatment directed at parents/caregivers:

Normal communication development and neonate’s capabilities, NICU environment & information will be used when compiling the tool in

Phase 2. staff, paediatric dysphagia and feeding therapy, identification of infant’s stress behaviour, developmental care, KMC, communication

The following is the role of the speech-language therapist in the NICU: parent education and counselling, staff and team education and collaboration (ASHA, interaction with infant, developmental milestones & follow-up after discharge.

2005:9). This includes information on developmental expectations, communication interaction patterns, as

-

Treatment directed at staff/team:

Developmental care, KMC & ECI, role of speechlanguage therapist in neonatal nurseries. well as feeding and swallowing, and contributing to the supportive and nurturing environment in the NICU to prevent negative sequelae (ASHA, 2005:9). Consequently it is important to find out whether participants have a need for tools directed at parents or team members in this regard, as this information could be used in compiling the tool during Phase 2.

ASHA (2005)

Billeaud and

Broussard

(2003)

Rossetti (2001)

Van Rooyen

(2006)

Ziev (1999)

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3.5.3.3 Pilot study

A pilot study was conducted to pre-test the questionnaire and to determine the efficacy and practicality thereof. A pilot study provides the researcher with the opportunity to modify the questionnaire and correct any errors at low cost before the main study is conducted (De Vos et al., 2005:177). The main value of a pilot study is that it aids in solving problems that otherwise might not have been anticipated in the course of the actual study (Maxwell &

Satake, 2006: 102). The pilot study is described in Table 3.3.

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Table 3.3: Description of the pilot study

Aims

To determine the amount of time needed to complete a questionnaire.

To determine whether the terminology and questions are clear and unambiguous.

To determine whether there are sufficient options provided in the questions.

To determine whether there are errors that the researcher should rectify before commencing the study.

Participants

The pilot study was conducted using three speechlanguage therapists who met the selection criteria.

These therapists were not included in the main study.

Materials

The questionnaire

(Appendix D) was provided as well as a checklist to evaluate the questionnaire

(Appendix E).

Procedures

Informed consent was obtained and the aim of the study was explained verbally and in writing.

Thereafter the participants were informed of the fact that the information would be handled in a confidential manner and that their names would not be revealed.

The participants were provided with the questionnaire by facsimile and by email. They were given enough time to complete it.

Results

Participants agreed that the questionnaire could be completed within a reasonable time.

The numbering of the questions was incorrect and was changed subsequently.

Terminology and questions were found to be clear and easy to understand.

The questions were found to have sufficient options.

The questionnaire’s format was found to be functional, but it was felt that the tables included should not flow over two pages. The researcher made the necessary corrections to the layout before commencing the study.

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3.5.4 Validity and reliability of the questionnaire

Validity is the extent to which an instrument measures what it is intended to measure (Leedy & Ormrod, 2005:92). The following strategies were used in ensuring validity in this study:

Construct validity: Construct validity is the extent to which an instrument measures a characteristic that cannot be observed directly but has to be inferred from patterns in people’s behaviour (Leedy & Ormrod, 2005:92). In this study speech-language therapists’ and audiologists’ perceptions of their roles, their competence, work satisfaction and their needs were constructs that could not be measured directly.

The construct validity could therefore be influenced by the participants’ subjective opinions and by the wording of questions in the questionnaire.

Content validity: Content validity refers to the degree to which a measure covers the range of meanings within a concept (Babbie, 1995:128). A thorough review of relevant literature in the field of neonatal communication intervention served as theoretical underpinning for the questionnaire.

Therefore it was assumed that the questionnaire measured the concepts that it should (De Vos et al., 2005).

The content of the questionnaire was reviewed by a statistician to determine whether the questions were relevant and appropriate for statistical purposes.

The construct and content validity of the questionnaire was determined by making use of a pilot study, and certain changes were implemented according to the recommendations made. The pilot study thus contributed to the study’s content and construct validity as it evaluated whether the questionnaire’s language was clear and unambiguous (De Vos et al., 2005:167).

External validity: Participants in a research project need to be a representative sample in order to draw certain conclusions about this population (Leedy & Ormrod, 2005: 100). Due to the small sample size, the results of this survey were not representative of the perceptions of all speech-

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Chapter 3 language therapists and audiologists employed in government hospitals.

Therefore no attempt will be made to generalise the findings.

Reliability: The reliability of an instrument is the extent to which it yields consistent results when the characteristic that it measures hasn’t changed

(Leedy & Ormrod, 2005:93). The questionnaire was piloted to determine whether any items were misleading or unclear, which could result in participants misinterpreting some of the items. The pilot study therefore also contributed to the reliability of the questionnaire. The data collection procedures were described in detail, contributing to the repeatability of the study and thereby increasing its reliability.

3.5.5 Data collection procedures

The following procedures were followed in the data collection:

Conditional ethical clearance was obtained from the Research

Proposal and Ethics Committee, Faculty Humanities, University of

Pretoria to conduct the research and to gain permission from the provincial Departments of Health to conduct the study. Once proof of permission from the provincial departments of health was submitted, final ethical clearance was obtained.

After contacting the provincial departments of health telephonically, permission was obtained in writing from the provinces of Gauteng,

KwaZulu-Natal, North West, Mpumalanga, Northern Cape and Eastern

Cape to perform the study. A list of the speech-language therapists and audiologists employed at hospitals together with their contact information was also obtained.

The targeted participants were contacted telephonically and the aim of the study was explained. The contact information of the participants who were interested in participating was verified and the researcher established whether they would prefer receiving the questionnaire by facsimile or e-mail.

The selected participants who agreed to participate were sent the cover letter and questionnaire by facsimile or e-mail.

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Follow-up telephonic contact was used to increase the return-rate of the questionnaires. The participants were contacted telephonically two weeks after the materials had been sent. In cases where there was still no response after four weeks, contact was made again, telephonically or via e-mail. Final contact was used six weeks after the questionnaires had been sent out, in order to increase the return rate.

No further requests were made hereafter, as participation in the study had to be voluntary.

3.5.6 Data analysis and statistical procedures

The following procedures were followed during data analysis:

The 41 returned questionnaires were coded and edited for obvious errors.

The data was processed utilising a statistical analysis computer package, namely SAS (SAS Institute Inc., 2000). Frequency distribution was set up from the raw data to obtain an overall view of the data (Maxwell & Satake, 2006:285). Descriptive statistics were used to examine and graphically display the data (Maxwell & Satake,

2006:280). MS Excel ™ was used to create graphical depictions of data as it allows the researcher to manipulate the displayed data easily

(Leedy & Ormrod, 2005:249).

The chi-squared test was performed in order to determine the independence between two or more nominal variables (Maxwell &

Satake, 2006:337). The test consists of setting up contingency (twoway) tables to explore the possible relationships between variables in the questionnaire (see list of variables in Appendix F).

An expected cell frequency of less than five was found, possibly due to the small sample size. The small sample size is partly due to the specialised nature of this study, but also because only six of the nine provinces granted permission for the study. In order to overcome this problem the data had to be regrouped by combining specific columns that belong together. After regrouping the columns, the expected cell frequency still did not comply with the validity rule. Therefore the chi-

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Chapter 3 squared test was not a valid test and was not utilised during data analysis in this study. The rule of five requires that the expected frequency for each cell be at least five in order for the discrete distribution of the test statistic to be adequately approximated by the continuous chi-squared distribution (Keller & Warrack, 2000:548).

Only descriptive statistics were used to describe and interpret the results.

The qualitative data was presented as detailed textual descriptions and

Phase 1 included direct quotations from participants (Fossey, Harvey,

McDermott & Davidson, 2002:730). The findings were discussed and interpreted in such a way that it is visible and comprehensible to the reader (Fossey et al., 2002:730).

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Chapter 3

3.6 PHASE 2

3.6.1 Objectives

The objectives of Phase 2 were:

To select and justify a specific need in terms of neonatal communication intervention instruments/tools in this context.

To compile a neonatal communication intervention instrument/tool based on the selection of one of the perceived needs of the participants.

To pre-test the completed instrument/tool and make changes if necessary.

3.6.2 Data collection procedures

The needs analysis in Phase 1 informed the nature and the format of the instrument/tool, which was compiled during Phase 2. Therefore the compilation of the instrument/tool could only be performed after the results of

Phase 1 were obtained. For this reason, the instrument/tool was pre-tested in a pilot study as part of Phase 2 and presented in Chapter 4.

The compilation of the tool involved a series of procedures and decisions

(Popich, 2003:31). The following procedures were followed during Phase 2 for determining the neonatal communication instrument/tool to be selected and for the compilation thereof:

The needs expressed, as well as the roles performed by the speechlanguage therapist participants as determined in Phase 1 of the study, were arranged according to the frequency of their selection and collated in tables.

These results, together with the current literature on the topic, were used to inform the selection of a need expressed by the participants to be addressed in the development of the instrument/tool.

The researcher subsequently determined goals and purposes for the instrument/tool (Popich, 2003:31).

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The researcher compiled the content of the neonatal communication intervention instrument/tool by developing a new tool based on current

ECI literature (see Table 4.6 in Chapter 4).

The instrument/tool was pre-tested in a pilot study (see Table 4.7 in

Chapter 4) after it was compiled, in order to determine its clinical applicability and assist the researcher in refining the instrument/tool.

3.6.3 Trustworthiness issues

The trustworthiness of the preliminary compiled instrument/tool was important as it was necessary to determine whether this instrument/tool is authentic, sound and representative of the context from which it was derived (Fossey et al., 2002:723). Dependability is an alternative to reliability and reflects whether there was consistency in the procedures that were followed (De Vos et al., 2005:346; Popich, 2003:60). By providing a detailed description of the procedures followed during the compilation of the neonatal communication intervention instrument/tool in Phase 2, the instrument/tool’s dependability was enhanced. The meticulous planning of the compilation of the instrument/tool therefore increased the trustworthiness of the study. Piloting the neonatal communication intervention instrument/tool also contributed to the trustworthiness, as it evaluated whether the language, terminology and content of the instrument/tool was appropriate for the population it was intended for.

The goal of credibility is to demonstrate that the inquiry was conducted in such a manner as to ensure that the subject was accurately identified and described (De Vos et al., 2005:346). The instrument/tool was compiled after completing a comprehensive review of relevant ECI literature prior to the development thereof. The trustworthiness was therefore enhanced as the instrument/tool had a strong theoretical basis.

Confirmability is the extent to which another individual can confirm the findings of the study (De Vos et al., 2005:347). Confirmability was established by consulting two professionals and lecturers at the Department

Communication Pathology, University of Pretoria in this particular field of

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Chapter 3 interest to gain insight from their expertise (Popich, 2003:61) to enhance trustworthiness.

3.7 CONCLUSION

The research problem that was identified was addressed by the preliminary compilation of a neonatal communication intervention instrument/tool for use by speech-language therapists working in local neonatal nurseries of public hospitals. This study entailed descriptive, exploratory research to provide a detailed picture of a situation or phenomenon that was not well-known, namely speech-language therapists’ and audiologists’ perceptions of their roles and needs in the context of the neonatal nursery. The questionnaire, which was used to gather participants’ perceptions of their roles and needs in this context during Phase 1 of the research, had a sound theoretical base as it was developed with careful consideration of current literature. The methods and procedures utilised in Phase 2 was described in a transparent manner so as to enhance the trustworthiness of the results. The speech-language therapists and audiologists contributed by providing their opinions on how to fulfil their real needs in this context, which resulted in the compilation of an instrument/tool for use by this population. The current literature on neonatal

ECI served as theoretical underpinning for the development of a neonatal communication intervention instrument/tool for use in local neonatal nurseries.

3.8 SUMMARY

Chapter 3 provides a framework for the planning and the implementation of the study. The researcher performed a needs-analysis among speechlanguage therapists and audiologists and subsequently selected a need for which a neonatal communication intervention tool was compiled. Ethical implications pertaining to this study were discussed. The participants were described in terms of their qualifications, years experience in the government sector and province of employment to interpret the findings accurately. The process of developing the materials used for this study was explained. Issues

89

Chapter 3 relating to reliability, validity and trustworthiness were discussed. Procedures for data-collection and data-analysis were documented. A detailed description of the method used in this study provides a structure for the description of the results.

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Chapter 4

CHAPTER 4

Results and discussion

______________________________________________________________________________________________

4.1 INTRODUCTION

Approximately 15% of infants born in South Africa are born prematurely (Lubbe,

2008:23) and those admitted to the NICU are cared for by many different professionals (Billeaud & Broussard, 2003:84). Speech-language therapists and audiologists play a critical role in the treatment of these at-risk infants in the

NICU (ASHA, 2005:2; Billeaud & Broussard, 2003:83). However, they require certain tools in order to perform their roles and responsibilities effectively.

Furthermore, professionals who provide neonatal communication intervention in local provincial hospitals are challenged by factors such as large caseloads, limited access to trained interpreters and a lack of culturally and contextually appropriate assessment and intervention tools. ASHA (2005:2) states that speech-language therapists need to develop culturally appropriate programmes that meet the needs of ethnically and linguistically diverse families. Therefore best practice in developmental care in South African neonatal nurseries needs to be facilitated through contextually appropriate tools.

Basing clinical decisions on scientific research is fundamental to ethical practice in ECI (Louw, 2007 [a]).

Against this theoretical background the current study aimed to compile a locally relevant neonatal communication intervention tool for use by speech-language therapists/audiologists. A needs analysis was conducted in order to establish whether a specific neonatal communication intervention tool is necessary to overcome some of the mentioned challenges. The aim of Chapter 4 is to present the results of this study in graphs and tables and to interpret these findings in answering the research question posed. The results of the two phases will be

91

Chapter 4 discussed separately as the findings of Phase 1 determined the type and format of the instrument/tool discussed in Phase 2.

4.2 RESULTS OF PHASE 1

The results of Phase 1 reflect the information obtained from the self-designed questionnaire which was completed by 41 participants. Two participants were qualified as audiologists only and therefore their responses are discussed separately. Due to the fact that audiologists perform a different role to speechlanguage therapists in the neonatal nursery, their responses would have impacted upon the results from the rest of the participants and were therefore kept separately. Specific variables utilised in data-analysis are referenced with variable numbers (e.g. V1, VV1), which are included in the list of variables in

Appendix F.

4.2.1 Objective 1: To describe the perceptions of speech-language therapists and audiologists providing ECI services in provincial hospitals regarding their roles in neonatal nurseries

Speech-language therapists’ perceptions of their roles where obtained from question B11 in the questionnaire regarding screening and assessment of the infant, intervention directed primarily at the infant and parents/caregivers, and intervention directed primarily at the staff/team members.

4.2.1.1 Screening and assessment of infants

According to Figure 4.1 the role in terms of screening and assessment, which were performed by the majority of participants, were assessment of the infant’s

feeding and oral sensori-motor functioning. This finding concurs with ASHA’s

(2005:5) description that the assessment of feeding and swallowing behaviour, including pre-feeding skills and promotion of readiness for oral feeding is an important role of the speech-language therapist. Goals of assessment include

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Chapter 4 identification of family concerns, priorities and resources, identification of the infant’s strengths and needs, identification of the focus of intervention, reinforcing parents’ feelings of competence and worth and developing ownership of decisions and plans by all parties concerned (Weitzner-Lin, 2004:25).

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Hearing screening (VV60)

Assessment of mother-infant-communication-interaction (V49)

Assessment of communication development (VV48)

Utilizing video-fluoroscopic studies for assessment of swallowing disorders (VV47)

Assessment of feeding and oral-sensorimotor function (VV46)

5

20

74

79

84

0 10 20 30 40 50 60 70 80 90

Percentage participants

Figure 4.1: Speech-language therapists’ indication of their roles regarding screening and assessment of the infant (n = 39)

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According to Figure 4.1 other roles that were performed by most of the speechlanguage therapists were the assessment of mother-infant communication

interaction and assessment of communication development. Speech-language therapists need to monitor mother-infant interaction closely, as it is important for the development of cognitive, social and linguistic skills in children (Rossetti,

2001:12). Assessment should provide baseline information that can be used to determine effectiveness and accountability of intervention programmes

(Wolraich, Gurwitch, Bruder & Knight, 2005:136).

The role that was least performed was video-fluoroscopic studies for the

assessment of swallowing problems, as illustrated in Figure 4.1. These results confirm those of Louw (2007:51, [b]) who studied the ECI service delivery of a group of community service speech-language therapists in four provinces and found that only one of 28 participants in her study utilised video-fluoroscopic studies as a diagnostic tool. Video-fluoroscopic instrumentation is not readily available at all hospitals and is usually only found in tertiary or academic hospitals, due to the costs involved. This finding can be explained by the fact that most of the participants were employed at district or regional hospitals that would not have specialised equipment such as video-fluoroscopy (refer to Figure

3.7).

Hearing screening was also performed by a small number of speech-language therapists, according to Figure 4.1. It appears that only a small percentage of participants fulfil the role of audiologist in the neonatal nursery, although many

(46%) of the participants were qualified as both speech-language therapists and audiologists (refer to Figure 3.2). This may be attributed to the limited availability of audiometric equipment, which is a recognised challenge in the South African public health sector. The results confirm the findings of Theunissen and

Swanepoel (2008:27) who determined that a lack of appropriate equipment was the most frequent reason for the absence of neonatal hearing screening programmes in the public health sector.

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Apart from performing roles that require specialised equipment such as hearing evaluation and video-fluoroscopy, speech-language therapists appeared to be performing multidimensional professional roles relating to screening and assessment, which is attributed to their awareness of the risks of development problems in the areas of attachment and communication development.

4.2.1.2 Intervention directed at the infant and parents/caregivers

The speech-language therapist’s role in the neonatal nursery includes providing feeding and swallowing intervention and communication intervention by guiding, educating and counselling parents/caregivers, developing programmes and advocacy, e.g. regarding developmental care (ASHA, 2005:2; Rossetti,

2001:174). According to Figure 4.2, it is encouraging to note that the majority of the participants in this study (82%) indicated that they were performing these roles in their hospitals.

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Counselling & support of parents/caregivers (VV59)

Informing parents, family members & caregivers of infant’s condition, progress and future expectations

(VV58)

Discharge planning & planning of follow-up treatment/management programmes after discharge (VV56)

Intervention in the form of encouragement/promotion of Kangaroo Mother Care (VV53)

Intervention in the form of applying Developmental Care (VV52)

Intervention for feeding problems & prevention of communication delays through parent guidance (VV51)

56

58

64

71

82

82

Intervention for feeding problems i.t.o. direct treatment with infant (VV50)

82

0 10 20 30 40 50

Percentage participants

60 70 80 90

Figure 4.2: Speech-language therapists’ roles in intervention specifically directed at the infant and

parents/caregivers (n = 39)

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The role least performed was discharge planning and planning of follow-up

treatment after discharge. Most speech-language therapists were the only speech-language therapist/audiologist employed in their department and had large caseloads (refer to Figure 3.9), which possibly did not leave time to engage in discharge planning and planning of follow-up services. Due to patients living across a wide geographical area and having limited finances and transport to return to the hospital or clinic, regular follow-up services are problematic in the

South African public health sector (Fair & Louw, 1999:13; Van Rooyen, 2006:42).

Early interventionists, however, need to be sensitive to family needs during an infant’s transition home, as efficacy of early intervention services is greatly enhanced if careful hospital discharge is completed before the infant goes home

(Rossetti, 2001:277).

Intervention in the form of the promotion of kangaroo mother care (KMC) was performed by only 58% of the participants. The benefits and cost-effectiveness of KMC have been proven in the literature and it is successfully implemented in a number of public hospitals in South Africa (Bergh & Pattinson, 2003:709). KMC leads to more efficient use of staff and can successfully be implemented in provincial hospitals (Cattaneo et al., 1998:281; Dippenaar et al., 2006:16a).

Many hospitals in the public sector, however, have not yet embraced the approach of KMC and in such contexts it may have been difficult for the participants to promote KMC. It is also possible that not all participants had received training in KMC, either on an undergraduate level or through continuing professional development, which could have prevented the participants from performing this role. This is evident from a participant’s comment in an open question (D5):

“…therapists need to become more aware of effectiveness of KMC.”

In conclusion, the majority of the participants reported that they fulfil a number of roles in direct intervention with infants and parents. Given the nature of the

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South African context, the roles performed by the participants need to be expanded and adapted to meet local needs to improve neonatal communication intervention service delivery.

4.2.1.3 Intervention directed at staff/team members

According to Figure 4.3 consultation with other professions in a multi- or

transdisciplinary team was a role that appeared to be performed the most frequently. It is positive that most participants (74%) were working as team members with other professionals, as this is preferred practice because of the benefits for the infant, family and the speech-language therapist. Early intervention in the NICU should follow a transdisciplinary team approach

(Rossetti, 2001:180). ASHA (2005:9) states that speech-language therapists may contribute to the NICU team’s developmental care plan with a focus on communication and feeding/swallowing.

In-service training & guidance of staff/team members (VV57)

64

Attendance of ward rounds with other professions (VV55)

28

Consultation with other professions in multi- or transdisciplinary team (VV54)

74

0 10 20 30 40 50 60 70 80

Percentage participants

Figure 4.3: Speech-language therapists’ roles in intervention specifically directed at staff and team members (n = 39)

In-service training and guidance of staff and team members were performed by only 64% of participants according to Figure 4.3. This is unsatisfactory and is

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Chapter 4 attributed to the fact that the role of the speech-language therapist is still not well known or acknowledged in the neonatal nursery, necessitating more in-service training to improve this aspect of service delivery. Staff/team education regarding developmental expectations, communication interaction patterns and feeding and swallowing behaviours is described as being an important role of the speech-language therapist in the neonatal nursery context (ASHA, 2005:9).

The role that was performed the least was attendance of ward rounds with other

professionals in the neonatal nursery. Ziev (1999:33) describes this function as an opportunity to learn from others and to become a familiar face among team members. It also presents the opportunity to request referrals based on infants’ symptoms or histories. As mentioned earlier, many participants were the only speech-language therapist/audiologist employed in their department (refer to

Figure 3.9). This could have limited their available time to attend neonatal ward rounds, as they might have been involved in other paediatric or adult ward rounds, clinics or consultations.

Most participants appeared to be aware of the impact they may have in this context through teamwork. However, in-service training of staff members was not yet performed by all and their service delivery was limited by poor attendance of ward rounds. This is problematic as many participants had limited experience, which resulted in missed opportunities in the neonatal nursery.

4.2.1.4 Audiologists’ perceptions of their roles in neonatal nurseries

Two of the participants in this study were qualified as audiologists only and the results of their responses are summarised in Table 4.1.

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Table 4.1: Audiologists’ roles in neonatal nurseries (n = 2)

Screening and assessment

Intervention directed at parents

Intervention directed at staff/team members

Roles

Assessment of neonate’s communication development

(VV48)

Assessment of feeding and oral sensori-motor function

(VV46)

Utilising video-fluoroscopic studies for assessment of swallowing disorders (VV47)

Assessment of mother-infant communication interaction

(VV49)

Hearing screening (VV60)

Intervention for feeding problems in the form of direct treatment of infant (VV50)

Intervention for feeding problems and prevention of communication delays in the form of parent guidance

(VV51)

Intervention in the form of applying developmental care

(VV52).

Intervention in the form of encouragement/promotion of full-time or intermittent kangaroo mother care (VV53)

Discharge planning and planning of follow-up treatment/management programmes after infant is discharged (VV56)

Informing parents, family members and caregivers of child’s condition, progress and future expectations

(VV58)

Counselling and support of parents/caregivers (VV59).

Consultation with other professions in a multi- or transdisciplinary team (VV54)

Attendance of ward rounds with other professions (VV55)

In-service training and guidance of staff/team members

(VV57)

Audiologists

1

0

0

2

1

0

0

1

1

2

2

0

2

0

1

Only one of the two audiologists performed hearing screenings, which is ascribed to the fact that hearing screening equipment is not readily available in government hospitals (refer to Figure 3.1) (Theunissen & Swanepoel, 2008:27).

Both audiologists worked as part of a team and consulted with other team members in accordance with ASHA’s guidelines for audiologists (2004:5 [a]).

Current literature emphasises the importance of ongoing audiological and medical monitoring of any child who demonstrates risk indicators for delayed onset or progressive hearing loss for at least three years (Northern & Downs,

2002:269). Interestingly, both audiologists also assisted in discharge planning and planning of follow-up treatment/management after discharge while only half of the larger group of 39 speech-language therapist participants performed this

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Chapter 4 role. This may be due to a lack of infant follow-up clinics at many district or regional hospitals. Families need information, consistent encouragement, reassurance, and positive feedback regarding their competency and ability to cope with the birth and hospitalisation of their critically ill newborn (Cone,

2007:37; Northern & Downs, 2002:152). It is therefore encouraging that both audiologists were involved in the planning of follow-up services.

According to Table 4.1 the role of the audiologist in the neonatal nursery is clearly defined by his/her profession and differs from the role of the speechlanguage therapist. ASHA (2004:5 [a]) describes the practice of audiology as prevention of hearing loss, identification of dysfunction in the auditory system, assessment of auditory function and referral to other professionals, rehabilitation, advocacy and consultation with other team members. The audiologist participants appeared to perform their expected roles, as indicated in literature, except for the one audiologist who did not perform hearing screening. This could be explained by the possibility that he/she did not have adequate testing equipment to perform this role.

4.2.1.5 Participants’ perceptions of competence and work satisfaction

The following information was obtained from all 41 participants in response to questions B6 – B10 in the questionnaire regarding their competence and work satisfaction.

a) Participants’ perception of their competence in the neonatal nursery

According to Figure 4.4, 53% of the participants indicated that they “sometimes”’ felt competent working in the neonatal nursery, which is disturbing considering the current emphasis on competent, well-trained speech-language therapists and audiologists in the context of the neonatal nursery (ASHA, 2004:159 [b]) and on the provision of quality care. Incompetence among speech-language therapists and audiologists may result in lost opportunities to provide intervention for the high risk neonatal population.

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53%

Most of the time

Sometimes

Rarely

Question unanswered

32% 10%

5%

Figure 4.4: Participants’ perceptions of competence in neonatal nursery

(n = 41)

The participants’ perceptions of their competency are displayed in Figure 4.5.

Participants could select more than one option and therefore the total of responses is more than 41.

63

70

60

50

40

30

20

10

0

4

41

17

24

31

Reasons for competence

Figure 4.5: Participants’ reasons for competence (n = 41)

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Many participants attributed their feelings of competence to their undergraduate training, which confirms Louw’s (2007:62 [b]) findings that 57% of the respondents in her study felt that they had sufficient undergraduate training to provide ECI.

Few of the participants (24%) attributed feelings of competence to advanced training in the field. As 60% of participants were recently qualified and had not yet had the opportunity to undergo advanced training (refer to Figure 3.4) this finding was to be expected. De Beer (2003:52) investigated the roles of speechlanguage therapists in the NICU and found that most of the speech-language therapists in her study had attended continued education seminars and courses on ECI. Speech-language therapists and audiologists have a professional responsibility to develop professionally and are mandated by the HPCSA to participate in CPD (HPCSA, 2002). Participating in CPD activities is therefore strongly recommended for the participants who are concerned about their competency in the neonatal nursery.

Only 2% of participants cited post graduate studies as their reason for feeling competent, which corresponds to the fact that only 10% had postgraduate qualifications (refer to Figure 3.5). Postgraduate qualifications in South Africa are mostly research-based and may improve theoretical knowledge, but not necessarily clinical expertise. Formal academic qualifications are therefore not an optimal strategy to improve clinical competence in neonatal communication intervention.

b) Participants’ perceptions of their work satisfaction

The majority of the participants enjoyed their work in the neonatal nursery “very

much” according to Figure 4.6. Louw, Van Eede and Louw (1998:538) describe work satisfaction according to intrinsic factors and extrinsic factors of work. The characteristics of employment (such as the challenges involved, how interesting

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Chapter 4 the work is) as well as the specific skills the employment entails, are intrinsic factors related to work satisfaction.

70%

15%

Very much

A little bit

Question unanswered

15%

Figure 4.6: Participants’ enjoyment of their work in neonatal nursery

(n = 41)

Extrinsic factors determining work satisfaction are salary, convenience, working environment and working hours (Louw et al., 1998:538). According to Louw et al. (1998:538) employees who focus on intrinsic factors have more work satisfaction, are more motivated and show more personal involvement in their work. Speech-language therapists and audiologists need to be skilled in working with infants and families, but require work satisfaction in order to excel in their professions. People drawn to helping professions such as speech-language therapy and audiology, tend to be people-oriented and focussed on helping those in trouble (Lubinski, 2008:533). The enjoyment that participants experienced related to their work in the neonatal nursery, could be due to the fact that they were able to provide guidance and support to infants and families who were in need.

An open-ended question (B7) tapped the participants’ reasons for their positive experiences. Participants perceived their work in the neonatal nursery to be

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Chapter 4 challenging, and therefore they appeared to find it enjoyable. Challenges of a specific work are intrinsic factors of employment (Louw et al., 1998:538).

Intrinsic factors of a specific work may lead to increased work fulfilment resulting in increased motivation and personal involvement in the work. The following comments of participants attest to this:

“It is a challenging but very satisfying area. You sometimes see good results and happy families. We are always learning.”

“I find this a challenging and rewarding area. It is a broad and dynamic area...”

It is encouraging that participants mentioned the satisfaction that they experienced from working in a team, as is clear from their comments:

“...contact with the medical team...”

“Getting to work with other therapists, parents and nurses.”

De Beer (2003:53) determined that speech-language therapists enjoyed sharing information within a team, which verifies the current findings. The participants’ motivation for being involved in teamwork may be attributed to the fact that many were the sole professionals in their field at their hospital and lacked extensive experience, rendering team involvement to be a supportive and enriching experience.

Participants, however, also commented on their negative experiences in the neonatal nurseries in public hospitals in response to another open-ended question (B8) in the questionnaire . It appears that the role of speech-language therapists and audiologists in the context of the neonatal nursery is not wellknown among other team members in all neonatal nurseries. This was also identified as a barrier to ECI service delivery in the NICU by De Beer (2003:53).

Due to the introduction of PHC and the institution of community service, speechlanguage therapy and audiology posts in public health care have increased

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(Theunissen & Swanepoel, 2008:28). Some participants may be the first speech-language therapist and/or audiologist employed at their hospital and therefore ECI may not yet be well-known. Furthermore, high turnover of nursing staff in the neonatal nursery is common and necessitates speech-language therapists and audiologists to continuously forge relationships with staff

(Rossetti, 2001:274).

Ineffectiveness of co-workers may lead to stress, reduce work satisfaction

(Lubinski, 2008:529) and contribute to negative experiences of speech-language therapists and audiologists working in neonatal care. This is illustrated in the comments below:

“...SLT & A [speech-language therapist and audiologist] not regarded as an important member of the team.”

“Doctors and staff members not knowing my role as a speech therapist and my scope of practice.”

“Our profession is underestimated regarding the role we play in this context.”

Some participants mentioned the attitude of staff members regarding their recommendations as a reason why they did not always experience work satisfaction. This may be due to other staff not yet knowing or trusting a new speech-language therapist in their own working context. Participants might also have approached colleagues in a less than optimal manner and failed to impress them, due to their lack of experience. While early interventionists need to be brokers of information, it is important to monitor how information is shared and how quickly changes are expected in the NICU (Rossetti, 2001:275). Negative relationships between speech-language therapists and their co-workers may create situations where stress and burnout are likely to occur (Lubinski,

2008:529). Participants’ commented as follows:

“Nursing staff not always compliant with my recommendations.”

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“Working with team members who are not co-operative or who do not implement your suggestions.”

“The battle to implement change: getting other health care providers to understand the importance of positioning and sound reduction etc.”

Furthermore, language differences between participants and their patients appeared to be an aspect that influenced participants’ work satisfaction in the neonatal nursery. In light of South Africa’s multilingual society, as described in chapter 2, this is to be expected. Only 10% of participants had access to services of trained interpreters and assistants (refer to Figure 3.10), which explains the challenges of communicating with patients in their home language.

This also confirms Van Rooyen‘s (2006:25) findings that not all patients in public hospitals received ECI services in their home language and that services are primarily provided in English. According to one participant:

“Language differences make working with mothers difficult.”

Participants felt that the environment had an impact on their work satisfaction in this context. The high rate of low birthweight and premature infants in South

Africa (Pattinson, 2003:62) may explain the high number of infants and their mothers admitted in the wards. The comments that were shared are worrying:

“Very crowded.”

“Cramped conditions.”

“Hygiene is a big problem.”

Participants’ caseloads were described as not being ideal. Some participants had no supervision or support, which affected their work satisfaction. Speechlanguage therapists can experience stress and burnout resulting from large and

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“The fact that I am the only speech-language therapist.”

“I have no supervision thus I am faced with no support...”

Mentoring is beneficial in preventing stress and burnout, as it provides the opportunity to discuss problem areas and provide feedback, thus leading to increased work satisfaction (Lubinski, 2008:537). Therefore inexperienced speech-language therapists should be provided with ample opportunities to network with more experienced therapists so as to gain confidence in this context.

The following comments indicate that some participants felt that their undergraduate training had not equipped them sufficiently to experience work satisfaction. Due to the fact that most participants were inexperienced (refer to

Figure 3.4), they relied heavily on their undergraduate knowledge to guide their services in the neonatal nursery. Their perceptions that undergraduate training negatively affects work satisfaction may be because not all training programmes emphasise ECI during their undergraduate training. Inadequate training to comply with work expectations may contribute to chronic stress (Lubinski,

2008:529) and lead to less work satisfaction, as indicated by the comment below:

“I do not feel that I was exposed to this context at all during varsity.”

In conclusion, most participants experienced work satisfaction in the neonatal nursery. There are, however, aspects that challenge service delivery in the neonatal nursery in the South African context. It appears that the participants were more focused on the intrinsic factors of their work than the extrinsic factors,

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4.2.1.6 Improved future service delivery

The participants’ responses to Question C1 in the questionnaire regarding their opinions on what is required to improve future service delivery are summarised in Table 4.2 and discussed accordingly.

Table 4.2: Proposed future improvements regarding neonatal communication intervention service delivery (n = 41)

Area

Intervention

Staff/team

Improvements

Screening methods and/or equipment/materials (V66)

Assessment

Assessment methods and/or equipment/materials

(V67)

Intervention methods and/or equipment/materials

(V68)

Counselling methods (V69)

Time management (V71)

Team members (more/fewer team members, different specialisation, assistants/interpreters) (V70)

Personal improvement

Number and type of referrals from other professionals

(V65)

In-service training in hospital or province (V73)

Resources (literature, communication with experts)

(V72)

Continued professional development (CPD) (V74)

Participants

28

28

25

14

13

27

28

31

26

30

%

68%

68%

60%

34%

31%

65%

68%

75%

63%

73%

a) Assessment

According to Table 4.2 the participants experienced a great need for audiometric screening equipment. Many participants wanted screening services or equipment to be expanded in their hospital, and this as is clear from their comments:

“We have no OAE or ABR screener.”

“Audio screening is needed.”

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The results confirm those of Louw (2007:66, [b]) namely that few participants in her study had adequate equipment to conduct paediatric hearing screening and assessment in public hospitals.

Many participants wanted greater access to assessment methods and

instrumental assessments in order to improve their neonatal communication and feeding intervention, as is evident from the following comment:

“Video-fluoroscopy would be very handy!”

Some participants indicated in Table 4.2 that tools and materials for neonatal communication assessments were required to improve their ECI services. A number of locally developed neonatal communication assessment instruments is available (refer to Table 2.5). They are, however, not widely used in the public health sector and therefore not by the participants. These instruments have not been described and published other than in research reports and dissertations, and may therefore not be known to early communication interventionists. This is clearly illustrated by the following comments:

“We only have an informal assessment form.”

“I don’t have an assessment tool for neonates.”

b) Intervention

In Table 4.2 some participants listed that they required time management as a strategy to improve service delivery. This suggestion is related to large caseloads (refer to Figure 3.9) as well as administrative burdens typical of speech-language therapists and audiologists employed in the pubic health sector, and verifies Louw’s findings (2007:60, [b]) as well. According to Lubinski

(2008:543) speech-language therapists’ large and demanding caseloads can lead to stress and a feeling of ineffectiveness. This is evident according to the following statement:

“Lack of time remains an obstacle.”

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According to Table 4.2 counselling methods were identified by 34% of participants as an aspect requiring improvement. The majority of participants performed counselling as part of the services rendered to parents (refer to Figure

4.3). Effective reciprocal communication is essential to rehabilitative counselling.

Given the language and cultural barriers encountered, the use of professional and paraprofessional interpreters is essential during assessments and interventions (Rivers, 2000:67). However, the majority of the participants indicated that they work without the assistance of interpreters (see Figure 3.10).

The following statement attests to this:

“Need interpreters to help with counselling.”

The following section describes the improvements participants desired regarding their staff and team collaboration.

c) Staff collaboration and teamwork

According to Table 4.2 many participants desired more timely and appropriate referrals from other professionals in this context as indicated by their comments:

“Receiving limited referrals at present.”

“Patients are often referred just before discharge for a ‘quick fix’.”

Medical staff (e.g. doctors and nurses) may be unfamiliar with ECI and uninformed regarding the availability of ECI services in the hospital. The fact that few participants attended ward rounds with team members (refer to Figure

4.3) could be viewed as a missed opportunity for promoting the role of the speech-language therapist.

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As seen in Table 4.2, many participants indicated that they required more team members that had completed specialised training, as is clear from one participant’s comment:

“We have no paediatricians – rely only on community service medical doctors – it would be nice to work with specialised doctors.”

Most participants were employed at district or regional hospitals and also provided services at PHC clinics (refer to Figure 3.7), which possibly explains why the majority of the participants indicated that they worked with community service medical doctors in stead of specialists. As the most specialised neonatal care takes place in NICUs (Billeaud & Broussard, 2003:86) that are mainly located at tertiary or teaching hospitals, this finding could be expected.

A number of participants stipulated that they wanted to improve ECI services by having more speech-language therapists or audiologists in their department as is depicted in Table 4.2. As stated before, many participants were the only speechlanguage therapist/audiologist at their hospital (refer to Figure 3.9) resulting in large caseloads, which explains their comments:

“Need more SLT’s [speech-language therapists] – I am not really coping with the caseload.”

“Need audiologist.”

Working with interpreters or assistants was mentioned as an area that participants would like to see:

“Need more good interpreters.”

“Assistants and interpreters are needed as the bulk of our patients are Tswana-speaking.”

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The shortage of interpreters could possibly be due to limited funding in the

South African public health sector. This confirms the findings of both Louw

(2007:43, [b]) and Van Rooyen (2006:31) who reported that there appeared to be a shortage of trained, professional interpreters in certain provinces in the public health context. The absence of interpreters could influence ECI services negatively as language barriers have a significant impact on the relationship between the professional and the family (Madding, 2000:14).

d) Personal improvement

In Table 4.2 many participants indicated that they would like to develop professionally by attending more CPD activities. As discussed earlier, most participants were recently qualified (refer to Figure 3.4) and many were the only speech-language therapist or audiologist employed at their hospitals (refer to

Figure 3.9). The limited support and guidance that they experienced created a need to acquire new knowledge and skills through CPD activities. The Health

Professions Council of South Africa (2002) mandated that all speech-language therapists/audiologists participate in CPD to ensure that services are of a high standard, relevant, appropriate and up to date. However, CPD is costly and may not be as accessible in the public sector as in the private sector. This is clear from the following comments:

“Need funding for training.”

“CPD should be easier accessible.”

According to Table 4.2 many participants wanted to improve resources so as to enhance their ECI services in the neonatal nursery. Participants indicated that they required better access to recent literature as well as consultations with more experienced therapists:

“Would like access to journal articles.”

“Communication with experts would be nice – not a lot of senior therapists within this province.”

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This again reflects the participants’ inexperience and lack of support, although it does indicate that they are aware of the importance of evidence-based practice.

According to Rossetti (2001:177), learning from other professionals providing services in the NICU is a valuable capacity-building exercise.

In conclusion, speech-language therapists’ roles appear to be varied, complex and influenced by barriers in the environment. Some participants were inexperienced, which might have prevented them from performing some roles to the full. Participants provided ECI in a context that was characterised by many challenges and provided insightful suggestions to improve ECI service delivery locally.

4.2.2 Objective 2: To identify participants’ needs in terms of neonatal communication intervention instruments/tools

Speech-language therapists’ needs regarding assessment instruments or tools, intervention tools or materials for use with parents, staff and team members in neonatal nurseries were obtained from Sections C and D in the questionnaire.

The 39 speech-language therapist participants’ responses are described separately from the two audiologist participants. This is due to the fact that audiologists perform different roles in the neonatal nursery to speech-language therapists and would therefore require different materials or equipment.

4.2.2.1 Assessment instruments or tools

Figure 4.7 shows that, while some participants used tools and materials to conduct assessments, others did not. A clear need exists for assessment tools in the assessment areas of the neonate’s communication development, feeding,

mother-child communication interaction as well as the neonatal nursery

environment. This need expressed by the participants indicates that they were aware of the importance of assessing a range of areas and using the results to

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Chapter 4 improve developmental care in their respective hospitals. According to

Sutherland Cornett (2007:294) clinicians must adopt objective criteria for defining necessary services and provide a consistent clinical strategy for decision-making in order to render services that are evidence-based. It is best practice to utilise an appropriate instrument/tool for the assessment of the neonate’s communication development and feeding. Many participants were hampered in following best practice guidelines due to the lack of assessment tools.

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20

15

10

5

0

1

15

18

1

0

15

18

Chapter 4

16 16

2

0

1

19

1

8

3

Assessment areas

Figure 4.7: Needs regarding assessment instruments/tools (n = 39)

Don't have this tool, but don't think it's necessary

Don't have this tool, but would like to have it

Already have this and use it

Already have this, but don't use it

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4.2.2.2 Intervention tools/materials for use with parents/caregivers

According to Figure 4.8 many participants used an instrument/tool or materials to provide parent guidance in the areas of normal communication development,

developmental milestones and follow-up services, KMC, and communication

interaction with the infant. Although a number of participants appeared to be well-equipped with resources for parent guidance, there appeared to be a need for instruments/tools in the above-mentioned areas for use in the neonatal nursery by some participants.

Figure 4.8 also indicates that many participants did not have any instruments/tools or materials to use for parent guidance in the areas of the

neonatal nursery environment, paediatric dysphagia and feeding therapy, over-

stimulation and identifying infant’s stress cues and developmental care, which is indicative of another need. It is clear that participants cannot follow best practice if they do not have adequate instruments/tools and materials at their disposal.

The ultimate NICU-goal of facilitation and promotion of infant development is achieved by, among others, teaching parents to interpret infant behaviour and promoting parent-infant interaction (Merenstein & Gardner, 2002:234). The multilingual nature of the South African society and the high rate of illiteracy amongst South Africans make parent guidance a challenge. Trained interpreters are an invaluable asset, but most participants did not have trained interpreters at their disposal (refer to Figure 3.10). Tools or materials for parent guidance in provincial hospitals should therefore assist speech-language therapists who do not have access to trained interpreters.

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15

10

5

0

30

25

20

24

2

6

0

1

18

17

0 0

19

13

2

0

19

13

1

24

0

8

2

0

12

21

3

0

9

24

2

26

0

9

1

Topics for parent guidance tools/materials

Don't have this tool, but don't think it's necessary

Don't have this tool, but would like to have it

Already have this, and use it

Already have this, but don't use it

Figure 4.8 Needs regarding intervention tools/materials specifically focused on parents or caregivers

(n = 39)

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4.2.2.3 Intervention tools/materials for use with staff/team members

According to Figure 4.9 most participants expressed a need for in-service training tools/materials for staff and team members on the role of the speech-

language therapist in the neonatal nursery as well as developmental care. Few participants expressed a need for tools in the areas of KMC and ECI, which could indicate that they had sufficient materials to perform staff/team training in these areas.

Speech-language therapists in this study appeared to be enthusiastic about staff/team training as seen in Table 4.2. Participants would have liked to perform more in-service training in the context of the neonatal nursery. According to

Kraamwinkel and Louw (1998:46), an integral role of the speech-language therapist in the NICU is the training of staff members such as nursing staff, to move towards a transdisciplinary team approach. It is speculated that participants would possibly perform this function more frequently, and fulfil their role more effectively, if they had been equipped with the appropriate tools and materials to do so.

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5

0

15

10

25

20

1

23

7

2

0

Chapter 4

13

19

2

1

19

13

2

Topics for in-service training of staff members

Don't have this tool, but don't think it is necessary

Don't have this tool, but would like to have it

Already have this tool and I use it

Already have this but don't use it

Figure 4.9: Needs regarding intervention tools/materials focused on staff/team members (n = 39)

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4.2.2.4 Audiologists’ needs regarding clinical instruments/tools for assessment and intervention

The two audiologists’ needs for tools and materials are depicted in Table 4.3.

Table 4.3: Audiologists’ needs in neonatal nursery (n = 2)

Area Instrument/tool

Screening and

Neonate’s communication development (V82)

assessment

Mother-child interaction (V83)

Intervention directed at parents

Normal communication development (V84)

NICU/NHCU environment and staff members (V85)

Over-stimulation, identification of infant’s stress behaviours (V90)

Developmental care (V91)

Kangaroo mother care (V92)

Communication interaction with the infant (V93)

Developmental milestones and follow-up services after discharge from hospital (V94)

Intervention directed at

Developmental care (V100)

Kangaroo mother care (V101)

staff/team

Role of the speech-language therapist in neonatal care wards (V102)

Aud1 = Audiologist 1

Already have this

Aud2

Aud2

Aud2

Aud2

Aud2

Aud2

Aud2

-

-

-

Aud2

Aud1

Aud2 = Audiologist 2

Do not have this

Aud1

-

Aud1

-

-

-

-

Aud1

Aud1

Aud2

-

Aud2

Unsure

Table 4.3 indicates that only one of the two audiologists was equipped to perform

-

-

-

Aud1

-

Aud1

Aud1

-

-

Aud1

-

-

hearing screening, assessments and some aspects of parent guidance in the neonatal nursery. This confirms findings by Theunissen and Swanepoel (2008) who found that only 34% of participating government health care institutions had at least one piece of hearing screening equipment.

According to the Joint Committee on Infant Hearing (JCIH) Year 2007 Position

Statement, the success of early hearing detection and intervention programmes depends on professionals working in partnership with parents as a wellcoordinated team (JCIH, 2007:9). Roush (1991:49) states that the audiologist’s traditional role has focused primarily on the technical aspects of hearing measurement and amplification but also includes inter- and transdisciplinary

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Chapter 4 aspects of early intervention. It appears that services provided by audiologists in neonatal nurseries would be enhanced by the availability of more comprehensive tools for parent guidance and staff/team training.

4.2.2.5 General perceptions regarding instruments/tools

The following information was obtained from open questions C2 and C3 in the questionnaire regarding all 41 participants’ perceptions of culturally appropriate instruments/tools and user-friendly instruments/tools.

a) Perceptions of culturally appropriate instruments/tools

Some participants expressed a need for culturally appropriate tools for use in the neonatal nursery, specifically for parent guidance, as is evident from their comments:

“We need culturally appropriate tools. Most of the tools are British/American and so are not always appropriate for the SA context.”

“It would be helpful to have an assessment and intervention tool that is culturally appropriate and sensitive for patients that do not share the Western culture.”

“Huge need for educational materials for parents to inform them and assist them with decision-making, also to make them aware of their rights.”

This view is verified by Louw’s results (2007:62 [b]) who found that most of her participants required culturally appropriate materials for ECI. According to an asset-based approach, the cultural richness of the South African population could enhance early communication intervention services and could be achieved

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Chapter 4 by compiling culturally appropriate parent guidance tools for use in the neonatal nursery.

Some participants indicated that they had developed and adapted culturally appropriate tools themselves to improve their services in the neonatal nursery, as is clear from their comments:

“I have had to develop my own assessment tool based on a journal article I read.”

“We have quite a few adapted tools which work well.”

According to Louw (2007:51 [b]) respondents in her study adapted published programmes and developed language assessment protocols in different languages for use in their respective contexts, which confirms the above results.

The participants were creative, enthusiastic and determined to provide services in a challenging environment. However, the

development and adaptation of the tools were not research-based and their validity and reliability are as yet unproven, which means that evidence-based practice is not followed.

Participants also commented that a need exists for tools in other languages:

“We don’t have any culturally appropriate materials and find it very difficult to work with patients that don’t understand English or Afrikaans.”

“Not only should they be culturally relevant but also translated, or useful across languages.”

Multilingualism in South Africa is a barrier to ECI service delivery (Louw et al.,

2006:47), which as mentioned earlier, may be overcome by the use of trained interpreters. As mentioned previously, most participants did not have access to trained interpreters. This suggests that participants may have relied on

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Chapter 4 tools/materials to assist them to provide linguistically sensitive services in the neonatal nursery.

ECI services are required to be family-centred, as well as culturally and linguistically responsive (ASHA, 2008:2 [a]). Neonatal communication intervention services therefore cannot be effective without culturally appropriate tools. An urgent need for culturally appropriate materials for use in the neonatal nurseries of provincial hospitals was identified. Participants were aware of the importance of providing culturally sensitive services, but were hampered by the dearth of tools and materials that could be utilised in clinical practice.

b) Perceptions of user-friendly instruments/tools

The following comments were elicited in response to the open question C3 on the user-friendliness of instruments and tools. Many participants’ comments suggested that user-friendly instruments were needed as they were utilising selfdeveloped tools:

“Very much needed! At the moment our hospital is using a self-developed, screening tool that is adapted from text books…”

“There is a lack of assessment sheets specifically created for this environment, so I find myself creating my own.”

“An intervention tool is specifically needed especially to address SSB-problems [suck-swallow-breatheproblems] in infants…”

Some participants commented that user-friendly instruments/tools would improve their effectiveness as they had large caseloads:

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Chapter 4

“We don’t have any user-friendly instruments or materials or tools. It would be nice to have a quick/easy assessment tool – because there are many babies in the mentioned wards.”

“User-friendly tools help to save time so we can provide a better service to all referrals.”

The need for research-based, user-friendly instruments/tools for use by speechlanguage therapists in neonatal nurseries is evident.

4.2.3 Conclusion of Phase 1

Phase one of the research demonstrated that participants performed different roles in neonatal nurseries, which were determined by the environment, tools, materials and instrumentation available to them. Although many participants were relatively inexperienced, they were resourceful in their attempts to develop and adapt tools and materials. The fact that these self-developed and adapted tools are not published, compromises the quality of services and precludes best practice. The participants expressed a need for culturally appropriate and userfriendly instruments specifically for parent guidance and staff/team training.

These descriptive findings justify the compilation and development of a locally relevant instrument/tool for use in public hospitals’ neonatal nurseries.

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4.3 RESULTS OF PHASE 2

The results of Phase 2 describe the selection, justification and compilation of a tool based on the results of Phase 1. Phase 2 is described according to the subaims formulated in Chapter 3.

4.3.1 Objective 3: To select and justify a specific need of the participants in terms of neonatal communication intervention instruments/tools in the public hospital context

The selection of a need was based upon the responses obtained from the 39 speech-language therapist participants in Phase 1 as well as current literature in the field. The two audiologist participants’ opinions were excluded from the selection of the need from which an instrument/tool was compiled due to their limited numbers and as their roles in the neonatal nursery differed from the roles of the speech-language therapists.

4.3.1.1 Justification of the selection of a specific need: speech-language therapists’ needs and their roles

An overview of the needs of the speech-language therapists as determined in

Phase 1 (see Figures 4.7, 4.8 and 4.9) was compiled in Table 4.4 to justify the selection of a specific need.

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Chapter 4

Table 4.4: Speech-language therapists’ needs (n = 39)

Need Number of responses

(n = 39)

36

Number that indicated need

15

Assessment tools

Parent guidance tools

Staff/team training tools

Neonate’s communication development

Feeding

Mother-child communication interaction

Neonatal nursery environment

Neonatal nursery environment and staff

Paediatric dysphagia and feeding therapy

Over-stimulation, identifying infant’s stress cues

Developmental care

Kangaroo mother care

Communication interaction with infant

Developmental milestones & follow-up after discharge

Normal communication development

Developmental care

KMC & ECI

Role of the SLT in the neonatal nursery

34

33

33

36

34

35

35

35

35

34

36

36

35

36

15

16

19

24

18

19

19

8

12

9

9

23

13

19

%

41.6

44.1

48.4

57.5

66.6

52.9

54.2

54.2

22.8

34.2

26.4

25.0

63.8

37.1

52.7

Hierarchy

1 - 14

9

2

10

6

8

7

3

1

5

4

4

14

11

12

13

The five needs that were indicated most frequently by the speech-language therapist participants are highlighted in Table 4.4, namely tools for parent

guidance on four topics, a tool for staff and team training on one topic and an

assessment tool on one topic. An overview of the speech-language therapist participants’ roles (refer to Figure 4.7, 4.8 and 4.9) was compiled in Table 4.5 in order to justify the selection of a specific need

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Chapter 4

Table 4.5: Speech-language therapists’ roles (n = 39)

Need %

Assessment

Intervention directed at infant and parents

Intervention directed at staff/team members

Hearing

Mother-infant communication interaction

Communication development

Swallowing disorders using video-fluoroscopy

Feeding and oral sensori-motor function

Counselling and support

Informing parents of infant’s condition, progress & future expectations

Discharge planning, planning follow-up treatment programmes

Encourage/promote KMC

Apply developmental care

Intervention for feeding & prevention of communication delays through parent guidance

Intervention for feeding i.t.o. direct treatment of infant

In-service training & guidance of staff/team

Attendance of ward rounds with other professions

Consultation with other professions in multi- or transdisciplinary team

20

79

74

5

84

82

71

56

58

64

82

82

64

28

74

8

7

6

2

2

6

9

4

The five most frequent roles performed are highlighted in the Table 4.5, namely

intervention for feeding and prevention of communication delays through parent

Hierarchy

1 - 14

1

2

5

10

3

4

11

guidance, counselling and support and informing parents of infant’s condition,

progress and future expectations. Three of these five most frequent roles were roles directed at parents/caregivers, which provides a strong indication for the selection of a tool aimed at parents/caregivers.

The analysis and interpretation of the data revealed needs for tools or materials in all of the following areas: assessment/screening, instruments/tools for parent guidance and instruments/tools for staff/team members. The data revealed that there were a variety of topics that the participants preferred for inclusion in a tool or materials.

The need regarding parent guidance with the topic of developmental care was selected as the tool to be compiled as this was a need indicated by the majority

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Chapter 4 of the speech-language therapist participants and most participants were also involved in services directed at parents/caregivers in the neonatal nursery. The selection is further justified by current literature on the topic.

4.3.1.2 Justification of the selection of a specific need: current literature

Literature shows that the neonatal nursery environment has a negative effect on the premature infant’s development. The NICU is an environment of sensory bombardment with constant noise and light, upset sleep-wake cycles, multiple caregivers and intrusive or invasive procedures, which leads to long-term physiological instability and poor developmental outcomes (Merenstein &

Gardner, 2002:233). This environment interferes with an infant’s ability to interact with the environment in a normal manner, which could be a potential source of a communication development delay (Rossetti, 2001:1).

Individualised developmental care includes fostering neurobehavioural and physiological organisation of the infant’s systems to promote parent-infant attachment (VandenBerg, 2007:438). Developmental care should be consistently carried out by all health professionals during all care-giving across shifts to support the infant and attachment with the parents (VandenBerg,

2007:438). Involving families from an early stage in the developmental care of their premature infant can greatly assist in the attachment process and consequently reduce parental stress (Wyly, 1995:213).

KMC is another intervention that is beneficial to the attachment process. It is specialised care-giving intervention provided by nursing staff. KMC is a developmental care practice and a form of tactile-kinesthetic stimulation through skin to skin contact between the parent and infant (Rossetti, 2001:182).

Communication intervention is a specialised intervention provided by speechlanguage therapists and audiologists and a component of developmental care.

According to Rossetti (2001:275) parents in the NICU require information and

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Chapter 4 assistance in attaching to their child. Lack of proper attachment between the parent and the infant has long-term implications for children’s cognitive and social development (Rossetti, 2001:270). A predictable and responsive environment enables an infant to progress to varied types of communication (not only crying), while inconsistent cues from caregivers distress infants (Merenstein

& Gardner, 2002:236).

As previously mentioned in the discussion of the results of Phase 1, most participants were satisfied with their tools and materials on the topics of communication intervention as well as those who performed KMC. They indicated a preferred need for tools/materials to facilitate implementation of a comprehensive developmental care programme in the neonatal nursery.

Rakau (2005:40) studied mothers’ needs in an NICU of a public hospital in South

Africa and found that most mothers were unaware of the impact of the NICU’s high noise levels on their infants’ hearing. According to Popich et al. (2007:68) limited parental knowledge regarding risk factors may result in an increased risk for communication disorders. Parents should therefore be empowered with knowledge and information in order to prevent communication delays (Popich et al., 2007:68).

The majority of mothers in Rakau’s study expressed a need for further information on their infants’ medical and developmental needs and were concerned about future expectations of their infants (Rakau, 2005:41).

According to Merenstein and Gardner (2002:238) parents, with the support from professionals, are the ideal planners and providers of developmentally appropriate intervention strategies.

Based on the local need identified by Rakau (2005:42), a tool for parent guidance on the topic of developmental care was developed for use in local neonatal nurseries. Rakau (2005:42) recommended the provision of culturally

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Chapter 4 appropriate educational and counselling opportunities to families in the neonatal nursery, in order for them to express their needs openly in a non-judgmental arena. However, there is a shortage of published neonatal communication intervention tools/materials aimed at parents in the South African context (refer to Table 2.6). The compilation of tools/materials directed at parents on the topic of developmental care is therefore justified.

Parent education and guidance is challenging for most speech-language therapists due to the multilingual nature of the South African population. The use of trained interpreters is the ideal, but the majority of the participants in this study reported that they did not have these services at their disposal (see Figure 3.10).

Having tools/materials to rely on for parent guidance in ECI for use in public hospitals is an alternative for overcoming the barrier of a lack of interpreters.

During Phase 1 it was also established that many participants were relatively inexperienced and in most cases working without the guidance of a senior therapist. Locally relevant neonatal communication intervention tools or materials aimed at parents/caregivers in the neonatal nursery will guide such inexperienced therapists.

Furthermore, it appeared that many participants compiled their own instruments/tools, but that these self-developed tools were not research-based and therefore the recommended best practice was not followed. A researchbased neonatal communication intervention tool or materials for parents/caregivers may help to overcome this challenge and address the participants’ need for locally relevant tools/materials for the neonatal nursery.

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4.3.2 Objective 4: To compile a preliminary instrument/tool based on the selection of one of the perceived needs of the participants

The compilation of the tool, namely a programme, titled “Neonatal

communication intervention programme for parents” (see Appendix G) is described according to it’s aim, considerations for the training of adult learners, the structure and content, format and procedures.

4.3.2.1 Aim of the Neonatal communication intervention programme for

parents

The aim of the programme is to provide speech-language therapists in local public hospitals with a programme to educate and guide parents/caregivers of infants in the neonatal nursery including the NICU, the neonatal high care and the KMC ward, regarding developmental care and the appropriate interaction and stimulation of their infants.

4.3.2.2 Considerations for the training of adult learners

Parents must be well informed and educated if they are to fulfil a central role in the early identification and prevention of communication disorders, as not all parents are equally equipped to facilitate optimal communication development

(Popich et al., 2007:68). Malcolm Knowles introduced the term “andragogy” defining it as the ‘art and science of helping adults learn’. Knowles derived principles of andragogy, which are utilised as guidelines to teach adult learners who are independent and self-directed (Kaufman, 2003:213). The concept of adult learning was considered in the compilation of the “Neonatal communication

intervention programme for parents” to ensure that the programme could successfully be used for adult education with parents and caregivers at local public hospitals. The following adult-learning principles were applied from

Kaufman (2003), Parson (2001), Popich et al. (2007) and Popich (2003):

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Safe and supportive environment: Adult learners need support and constructive feedback from teachers and peers to practice newly-learned skills (Kaufman, 2003:215). A safe environment, where every person is respected encourages them to express their ideas freely and therefore more active learning is facilitated (Parson, 2001:30). A “warm-up” activity was incorporated into the introduction section of the programme, as this establishes rapport between the speech-language therapist presenting the programme and the parents/caregivers receiving the training. It also allowed for social contact between the parents/caregivers in order to encourage the sharing of opinions and asking of questions. The parents’ trauma of giving birth to preterm infants was considered during the compilation of the programme as this could have affected their learning.

According to Rakau (2005:40) mothers of infants in the NICU suffer significant symptoms of depression while their infants are hospitalised.

This may influence the mothers’ enthusiasm to participate in a training programme. The programme attempted to accommodate mothers who experienced emotional trauma.

Real-life situations: Problems and examples that are used in training need to be realistic as the adult must closely relate to understanding and solving real life problems (Kaufman, 2003:215). Photos and images of infants of various races were utilised to depict real situations in a similar setting (e.g. the NICU) to that of the infants of the parents/caregivers in the programme. This ensured that the programme is culturally appropriate and that the parents could identify with the situations depicted in the photos and images (Popich et al., 2007:76).

Recognise prior knowledge: The adult learner’s current knowledge and experience should be taken into account as it is a rich resource for learning (Kaufman, 2003:215). It was important to consider that while some parents/caregivers may have prior education or training, many

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Chapter 4

South Africans have limited literacy skills (Fair & Louw, 1999:14; Louw &

Avenant, 2002:149). All parents/caregivers were accommodated in the programme by using clear language and terminology as well as images and photos, to augment the written word in the presentation and to explain scientific concepts in the clearest way possible. The handout was also made available to distribute to parents/caregivers in both English and

IsiZulu, regardless of their literacy level. By sharing knowledge more effectively in different ways may empower families (Louw et al., 2006:53).

Providing parents with information in their home language addresses, to an extent, their feelings of incompetence and lack of knowledge (Louw &

Avenant, 2002:147).

Reflection: To reinforce the message, important information needs to be highlighted through the use of repetition (Popich et al., 2007:76). Adult learners should be given with time to reflect on their learning in order to reinforce positive behaviours and discourage negative behaviours

(Kaufman, 2003:215; Popich, 2003:45). The programme provided time for reflection and feedback during the conclusion. This will encourage the parents/caregivers to comment on their learning and to pose questions to the speech-language therapist providing the training.

4.3.2.3 Procedures followed in the compilation of the “Neonatal

communication intervention programme for parents”

The following procedures were followed in compiling the programme:

Participants’ perceptions of their roles and needs in the neonatal nursery were used to inform the selection of an instrument/tool.

Parent guidance tools/materials on the topic of developmental care were selected and justified based on the results of Phase 1 as well as on current literature on the topic.

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Chapter 4

The researcher formulated an aim and outcomes for the programme

(Popich, 2003:31).

Issues relating to adult training and education were studied before compiling the programme.

Informal terminology was used to make the language more accessible to the parents/caregivers. The term ‘baby’ is used in the programme instead of ‘infant’ as this is the term most commonly used by South African parents in conversation (Popich, 2003:39).

The structure and sequence of the programme was conceptualised and is illustrated in Figure 4.15. The researcher structured a warm-up activity in the first section of the programme as part of the introduction. Time for reflection and questions was planned for the closure of the programme.

This structure ensured that the principles of adult learning were applied throughout the programme discussed previously.

The researcher selected a format for the programme. It was decided that the programme should consist of a Microsoft PowerPoint™ presentation and a handout for the parents. The Microsoft PowerPoint™ presentation was provided in two different formats as it allows each speech-language therapist to select a method that is conducive to his/her working environment. Some speech-language therapists in public hospitals have limited technical resources and therefore the Microsoft PowerPoint™ presentation was provided on a compact disc as well as transparencies.

Subsequent to an in-depth review of current ECI literature, the researcher decided on the themes of the programme, which are illustrated in Table

4.16.

The complete programme was compiled thereafter and is contained in

Appendix G [i].

The Microsoft PowerPoint™ presentation was designed by the researcher and copied onto a compact disc and transparencies (see Appendix G [ii]).

As there is limited technology in some public healthcare facilities, it will be useful to have a choice between the programme’s two formats. Therefore

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Chapter 4 each speech-language therapist can select the appropriate format that suits his/her needs.

The handout was designed by the researcher. It is contained in Appendix

G [iii]. Handouts were provided to parents during the programme to generalise and reinforce the newly learnt information as well as to actively involve each parent during the presentation.

The programme was proof-read by an independent speech-language therapist and an occupational therapist that provide early intervention services in an NICU of a private hospital in Pretoria. Comments from the therapists were used to refine the content, terminology and format of the programme.

The content of the handout was translated from English to IsiZulu by a private translation service appointed by the researcher.

The programme was pre-tested in a pilot study as illustrated in Table 4.17 to determine its clinical applicability and assist the researcher in refining the programme.

The programme is also available on compact disc in the sleeve at the back of the dissertation.

4.3.2.4 Sequence and content of the “Neonatal communication intervention

programme for parents”

The programme is divided into four sections, which include an introduction with

“warm-up time” and definitions, information on the behaviours of the neonate, information on how parent should respond to these behaviours and a conclusion that informs parents of options for follow-up services and provides time for reflection and questions. The sequence and content of the programme is schematically represented in Figure 4.10.

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Chapter 4

Figure 4.10: Schematic representation of the content of the programme

The content of the programme is described according to the themes and the justification thereof in Table 4.6.

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Chapter 4

Table 4.6: Themes included in the programme

Topic/theme

Prematurity and low birthweight

Infant’s senses (tactile, auditory, visual, vestibular, proprioceptive)

Developmental care (general awareness)

Stress behaviour

Self-regulating behaviour

Rationale

Prematurity and low birthweight are risk factors for a developmental delay and more specifically a communication development delay.

Infant’s sensory capabilities are the basis for communication development.

Therefore it is important to educate parents about the neonate’s auditory, visual, tactile, proprioceptive and vestibular systems so that they can respond appropriately to the neonate. Facilitating adaptive parenting helps to overcome difficulties with attachment.

Developmental care has demonstrated decreased hospital time, decreased medical complications and increased motor and behavioural scores on assessments for infants treated with developmental care when compared with a control group.

General awareness by parents reduces the stressful impact of the neonatal nursery environment on neonate and family and is therefore an important aspect to include in guidance about communication development. Sensory input must be appropriate and individualised to the infant’s physiological and neurobehavioural tolerance.

Stress behaviour or signals are the neonate’s body language that is used to communicate that he/she cannot cope with the environment. The infant indicates that he/she needs a “time-out” from stimulation using stress behaviour or signals.

Attention to the infant’s thresholds for input is essential as care-giving must be infant-centred and not caregiver-centred.

Self-regulating behaviour assists the infant in calming him- or herself in order to recover from stressful stimuli. Teaching parents about infant cues and how to support the infant during stressful events can help parents appreciate the unique personality of their infant. Kangaroo mother care is included as an appropriate calming technique.

References

Rossetti (2001)

Lubbe (2008)

Van Jaarsveld (2004)

Wyly (1995)

Kritzinger & Louw

(2003)

Lubbe (2008)

Merenstein & Gardner

(2002)

McInroy & Kritzinger

(2005)

Goldberg-Hamblin et al.

(2007)

Lubbe (2008)

McInroy & Kritzinger

(2005)

Rossetti (2001)

VandenBerg (2007)

Lubbe (2008)

Rossetti (2001)

Van Jaarsveld (2004)

Wyly (1995)

VandenBerg (2007)

Lubbe (2008)

McGrath (2008)

Wyly (1995)

VandenBerg (2007)

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Chapter 4

Table 4.6: Themes included in the programme (continued)

Topic/theme

Noise in the nursery

Light in the nursery

Physical handling of the infant in the nursery

Adaptations in the nursery to reduce stimuli (noise & light reduction, clustered care)

Kangaroo mother care

Rationale

The NICU environment is filled with atypical high-frequency sound, putting the premature infant at risk for a noise-induced hearing loss. Noise can be an environmental stressor in the neonatal nursery and can lead to physiological instability in the neonate. Premature infants exposed to constant high levels of background noise may have difficulty to discriminate speech in background noise, which leads to disrupted auditory learning.

Bright light can be an environmental stressor in the neonatal nursery and can lead to physiological instability in the neonate. Infants born prematurely are at risk for visual problems and the harshly lit NICU environment can contribute to this.

Reduced illumination increases the infant’s stability, reduces the heart rate, blood pressure, respiration rate and motor activity.

Infant reactions to being touched may yield a series of startles and limb extensions, followed by flailing, arching and uncontrollable squirming, which leads to energy expenditure. Incorrect or excessive handling and invasive procedures can cause long-term physiological instability and over-stimulation in the infant, and affects the infant’s sleep-wake cycle.

Environmental factors can be additional risk factors for a developmental delay and should be closely monitored. Excessive noise, light, handling and movement can be overwhelming, which influences the neonate’s growth and development. A key element of NIDCAP is the creation of a calm NICU environment with adjustable low levels of light, minimal or low levels of sound and a calm ambience.

KMC is tolerated well by preterm infants with current and resolving illness. KMC improves temperature, saturation and interaction-attachment between mother and infant. KMC reduces the harmful effect of the environment on the neonate and is an effective way of providing developmental care in South Africa.

References

Kellam & Bhatia (2008)

Lubbe (2008)

Merenstein & Gardner

(2002)

Rossetti (2001)

Wyly (1995)

VandenBerg (2007)

Fielder & Moseley (2000)

Lubbe (2008)

Merenstein & Gardner

(2002)

Rossetti (2001)

Wyly (1995)

VandenBerg (2007)

Lubbe (2008)

Merenstein & Gardner

(2002)

Rossetti (2001)

Wyly (1995)

VandenBerg (2007)

Lubbe (2008)

McGrath (2008)

Rossetti (2001)

Wyly (1995)

VandenBerg (2007)

Kritzinger & Louw (1999)

Lubbe (2008)

Merenstein & Gardner

(2002)

Payne (2000)

Rossetti (2001)

Van Jaarsveld (2004)

Van Rooyen et al. (2002)

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Chapter 4

Table 4.6: Themes included in the programme (continued)

Topic/theme

Positioning

Calming techniques (e.g. swaddling, containment)

Communication stimulation

Feeding

Follow-up services

(general awareness)

Rationale

Premature infants who are positioned in supine for long periods of time without support can develop shoulder retraction and neck extension, reducing midline

References

Goldberg-Hamblin et al.

(2007) orientation. Correct positioning with blanket rolls, padding or loose swaddling facilitates flexor tone and has an organising effect, which decreases stress and enhances comfort.

Hunter (2004)

Lubbe (2008)

Merenstein & Gardner

(2002)

Rossetti (2001)

Wyly (1995)

Calming techniques assist neonates to become more stable and prevent Goldberg-Hamblin et al. disorganisation, so that the neonate’s energy can be used to grow. Body containment and a flexion position increases the infant’s feeling of security and enhances physiological stability.

(2007)

Lubbe (2008)

Merenstein & Gardner

A newborn infant is able to communicate with his/her parent using body language and eye contact. Communication stimulation within a developmentally supportive approach can elicit positive behavioural responses. A primary goal of developmental care is to foster a positive parent-infant relationship. Responsive interaction prevents over stimulation as the parent acts upon the infant’s cues and therefore provides developmentally appropriate input.

Feeding of a premature infant creates a context for communication stimulation and therefore it is included in the parent education. Parents need education and encouragement to successfully support their infant during oral feedings.

Follow-up services are limited in the South African context due to patients’ limited finances and problems with transport. Parents need to understand what to expect from their child, the importance of serial developmental assessments and how community health care can support their child’s development.

(2002)

Wyly (1995)

Lubbe (2008)

McInroy & Kritzinger (2005)

Merenstein & Gardner

(2002)

Rossetti (2001)

VandenBerg (2007)

Lubbe (2008)

McGrath (2007)

McGrath (2004)

Fair & Louw (1999)

Lubbe (2008)

McInroy & Kritzinger (2005)

Van Rooyen (2006)

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Chapter 4

4.3.2.5 Format of the “Neonatal communication intervention programme for

parents”

The programme consisted of two components: a Microsoft Powerpoint™ presentation and a handout. According to Louw and Avenant (2002:150) graphic materials such as home programmes should be used during intervention with families in South Africa so as to be culturally sensitive.

English is recognised as the language of science and commerce in South Africa

(Population Census Key Results, 2001) and therefore the content of the handout was compiled in English. Most speech-language therapists are proficient in

English and so it was appropriate that the programme was available to them in

English. The information in the handout was also translated into IsiZulu to address language barriers. IsiZulu was selected as it is the home language of almost a quarter of South Africans (Population Census Key Results, 2001).

IsiZulu is the language most spoken in South Africa and is understood by over

50% of the population (Population Census Key Results, 2001). According to

Louw and Avenant (2002:147) an interventionist can empower parents and caregivers by providing them with information in their home language. The programme can be used widely by providing the information in IsiZulu.

The programme was compiled to be a user-friendly tool. The decision was therefore taken not to include references in the text so as not to intimidate parents and speech-language therapists. The complete list of references is provided at the end of the programme and attests to the theoretical underpinnings (Popich, 2003:37).

Microsoft PowerPoint™ presentation: According to Rakau (2005:35) participants in her study preferred receiving information in a verbal rather than written format. Therefore a Microsoft PowerPoint™ presentation was compiled of the complete programme and copied onto a compact disc.

This allows speech-language therapists in well-equipped institutions to

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Chapter 4 present the programme orally in a professional manner. However, this could limit the use of the programme, as it only provides for speechlanguage therapists who have access to technology such as dataprojectors and computers. Therefore the Microsoft PowerPoint™ presentation was also provided on transparencies (one slide per transparency), in order to accommodate speech-language therapists with overhead projectors at their disposal (see Appendix G [ii]).

Transparencies are useful visual aids in working with a group of parents, but common errors such as having too many transparencies, small print, removing them too quickly or placing them crookedly should be avoided

(Curran, 1989:91). These aspects were taken into consideration during the development of the Microsoft PowerPoint™ presentation.

Handout: The programme also includes a handout for the parents (see

Appendix G [iii]). The handout is a summary of the complete programme and included photos and images to manage literacy barriers. The handout illustrates important information in the programme with images, photos and key terminology. Visual sources such as pictorial depictions can be used to manage language barriers (Louw, et al., 2006:53). The handouts were available in English or IsiZulu. It contained checklists complimented by photographs depicting key concepts and neonatal behaviours for the parents to complete during the presentation, which contributed to the interactive nature of the presentation. Speechlanguage therapists were advised to provide each parent with a handout, regardless of their literacy level (Kritzinger, 2007). The handout contained many images and photos depicting new concepts so as to aid parents with different levels of literacy. It was also important to show respect to each parent in the group by not discriminating on the basis of their literacy level.

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4.3.3 Objective 5: To pre-test the “Neonatal communication intervention

programme for parents”

The programme was pre-tested using a pilot study, which is described in Table

4.7.

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Table 4.7: Pilot study of the programme

Aims

1. To determine whether the proposed programme is useful and complies with its

aim.

2. To determine whether the terminology and language

usage are clear and unambiguous for parents/caregivers.

3. To determine the whether the programme’s format and presentation are userfriendly, applicable and of a good quality.

4. To determine the quality of the programme’s content.

5. To determine which

improvements should be made.

Participants

The programme was presented at a regional hospital by

Materials

Permission to involve three speech-language therapist participants who the participants in provided ECI in the NICU, neonatal high care and KMC the research was wards. The speech-language therapists at a regional previously obtained hospital that participated in Phase 1, was contacted from the provincial telephonically to conduct the pilot study. The speechdepartments of language therapy department at this hospital was health (Appendix A). presented with the programme. The department Participants were assigned three speech-language therapists, who were provided with a unknown to the researcher, to conduct the programme. cover letter

Two of these participants graduated from a university in

Gauteng and one participant graduated from a university

(Appendix H), the programme in the Western Cape. The participants had the following experience and qualifications:

(Appendix G), as well as a questionnaire

(Appendix H).

Participant

1

2

3

Years experience

< 3 years

< 2 years

< 1 year

Highest qualification

Bachelor degree

Bachelor degree

Bachelor degree

The programme was presented to two mothers in the KMC ward of the hospital. The participants had the assistance of a staff member as an informal interpreter during the presentation. A laptop computer was available for their use at their institution.

Procedures

The aim of this phase of the study was explained verbally and in written format.

The participants were provided with the programme, as well as a cover letter and questionnaire, and were given enough time to study it and use it.

The participants were requested to provide feedback on the programme by completing the questionnaires and providing comments in the spaces provided.

The participants sent back the questionnaires with their feedback on the programme.

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Table 4.7: Pilot study of the programme (continued)

1. Aim

Results

The aim of the programme was achieved, namely to provide speech-language therapists

2.Terminology and language

in local public hospitals with a tool to educate and guide parents/caregivers of infants in the neonatal nursery on developmental care, early communication interaction and appropriate stimulation. The following comment attests to this:

“The moms enjoyed the training and asked questions.”

The programme’s language and terminology was found to be inappropriate as seen from the comments:

“Language in the programme is not appropriate, especially for moms in the government sector.”

“Would be very difficult to explain the terminology without an interpreter.”

3. Format

Supporting the home culture and home language must be the cornerstone of programs that serve infants and toddlers (Madding, 2000:17). The programme’s language and terminology therefore requires further refinement in order to be sensitive to the families served.

The Microsoft PowerPoint™ presentation of the programme was judged to be good.

Participants felt that the programme’s different formats were probably useful in assisting with service provision in the neonatal nursery.

4. Content

However, a comment that was provided under the same heading contradicts this finding, as can be seen in the following:

“The powerpoint was unnecessary. The slides did not fully correlate with the handouts and was therefore confusing.”

The content of the programme was viewed to be adequate and was probably useful in assisting with service provision in the neonatal nursery. Comment regarding the length of the programme was made:

“Programme is too long. We conducted it in two sessions.

Each session lasted 40 minutes and had to be before/between moms’ feeding times. Due to time constraints it would be difficult to conduct such a detailed programme on a weekly basis.”

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Table 4.7: Pilot study of the programme (continued)

4. Content

(continued)

Results

This finding corresponds with the information obtained in Phase 1 that most participants have time constraints impeding their services in the neonatal nursery.

The participants commented on the content pertaining to the infant’s capabilities (vision, hearing, tactile, vestibular, proprioceptive). The participants were not sure how and infant’s vision may be influenced by oxygen provided in the neonatal nursery, as is evident from the comment:

“How does oxygen affect infant’s eyesight? Perhaps if the infant is on phototherapy, but even then, the infant’s eyes are always covered.”

This comment could be explained by the participants’ limited knowledge about retinopathy of prematurity (ROP) and the negative effect it may have on an infant’s vision. ROP is caused by abnormal growth of the blood vessels supplying the retina, which is usually due to an elevated oxygen saturation level for a sustained period of time

(Harrison, 2002; Lubbe, 2008:202). According to Lubbe (2008:202) ROP results in poor vision and occurs more frequently in very low birthweight infants admitted to NICUs without oxygen protocols.

The participants also commented that:

“Not all speech therapists have training in neurodevelopmental care or even paediatrics, therefore would be unfamiliar with the terms used in the programme.

Hence a strong need for terms to be defined in an accompanying glossary.”

This comment confirms Rossetti’s statement (2001:175) that a professional requires specialised knowledge to provide services in the NICU. However, ECI has now been included in all training institutions’ undergraduate programmes in speech-language therapy (Kritzinger & Louw, 2003:5), which implies that terminology used in the programme should not be unfamiliar to any speech-language therapist. The source of this comment may be found in the participants’ limited exposure to the specialised field of neonatal communication intervention. This finding corresponds with the results from

Phase 1, which indicated that many participants in the public health sector have limited experience affecting the quality of the services they provide in the neonatal nursery.

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Table 4.7: Pilot study of the programme (continued)

Results

5. Improvements

Participants provided comments on possible improvements that included the use of demonstration:

“We used a lot of demonstration. This was of great benefit to the moms and should be considered when using the programme.”

The use of demonstrations or modelling is essential and makes it easier for parents to apply theoretical knowledge (Louw et al., 2006:53; Popich, 2003:45). It may therefore be useful to incorporate more opportunities for demonstration into the programme.

Other comments were related to the parent handout:

“Pictures of stress cues must be clearer. Also illustrate each signal.”

“Please number stress cues.”

Visual sources such as pictorial depictions aid the speech-language therapist in overcoming language barriers when sharing knowledge with parents (Louw et al.,

2006:53). It will be valuable to develop the parent handout further by adding more illustrations.

Participants recommended that the programme be applied in the KMC ward rather than the NICU or neonatal high care ward:

“Programme is more appropriate for KMC unit as mom is with baby constantly. Not appropriate for NICU or high care wards as moms have higher stress levels due to their child’s medical condition. Their moms are also only with babies for feeding times.”

This confirms Kritzinger (2007) who stated that the KMC ward offers unique access to mothers and their high risk infants and provides opportunities for early intervention as the mothers are available frequently.

From the pilot study in Table 4.7, it is evident that the programme achieved its aim, but certain changes should be made to the language, terminology, content

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Chapter 4 and length in order to improve the quality and make it more user-friendly. The programme was deemed to be most appropriate for the population residing in the

KMC ward as the parents may be more readily available than the parents whose infants are admitted to the NICU and the neonatal high care ward. The pilot study also confirmed the findings from Phase 1 that participants’ inexperience may have prevented them from fulfilling their roles effectively due to limited knowledge of the specialised field of neonatal communication intervention.

4.3.4 Conclusion of Phase 2

From Phase 1 it was concluded that participants had a need for parent guidance

tools/materials on the topic of developmental care as this was one of their most frequently identified needs. During Phase 2 a tool/materials for parent guidance titled “Neonatal communication intervention programme for parents” was compiled and justified by participants’ roles and needs determined in Phase 1 as well as current ECI literature. The programme entailed a package of training aids for use by a speech-language therapist.

The pilot study concluded that the programme was enjoyed by the parents who received the training. It was further determined that the content was appropriate but that the programme should be more concise and shorter so as to be more user-friendly. The parent handout was deemed suitable for the training although contradictory ideas were provided regarding the Microsoft PowerPoint™ presentation. Certain suggestions for improvement of the programme were made during the pilot study such as providing a glossary of terms with definitions for therapists to use, adapting the programme’s language and terminology, changing the numbering in the handout and providing more illustrations of stress cues. These improvements were made and therefore the programme is ready for use in further research projects. The pilot study confirmed the results found in Phase 1, which determined that many speech-language therapists who provide neonatal communication intervention in public hospitals are inexperienced. This value of such a neonatal communication programme for use

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Chapter 4 by this population is therefore restated. The results led to certain conclusions being drawn in Chapter 5.

4.4 SUMMARY

In Chapter 4 the results were discussed according to the objectives. The two phases of the research study were discussed separately. In Phase 1 the results from the survey were described, which described speech-language therapists’ and audiologists’ roles in local neonatal nurseries. Phase 1 also described the participants’ needs in terms of tools for assessment, parent guidance and staff/team training. In Phase 2, a tool for parent guidance on the topic of

developmental care was compiled from ECI literature and was pre-tested. The chapter concluded with the finding that the programme achieved its aim but that certain adjustments should be made to the content and language to improve the quality and applicability of the programme. The improvements were made to the programme.

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Chapter 5

CHAPTER 5

Conclusion and recommendations

____________________________________________________________________________________________

5.1 INTRODUCTION

Healthcare is increasingly focusing on evidence-based practice creating a need to demonstrate the value of health interventions (Clark, Gibb, Hart &

Davidson, 2002:121). Clinicians must become proactive in looking for information to support clinical procedures and critical in assessing the available information (Plante, 2004:390).

Neonatal communication intervention is of utmost importance in a country such as South Africa where there is an increased prevalence of infants at risk for developmental problems (Kritzinger, 2000:9). In order to be effective in the NICU, speech-language therapists must provide and promote developmentally supportive, family-centred care (Ziev, 1999:33). Research has shown that the use of developmental care strategies can improve a number of outcomes for premature infants (Goldberg-Hamblin et al.,

2007:165).

The current research was conducted to investigate the roles of speechlanguage therapists and audiologists and their needs in the neonatal nurseries of the public hospitals of South Africa. The aim of this chapter is to reflect on the research, to present conclusions to the research questions stated earlier and to provide an evaluation of the study. Recommendations for further research are provided. The chapter concludes with final comments from the researcher.

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5.2 SYNOPSIS OF PREVIOUS CHAPTERS

In Chapter 1 a rationale for the research was formulated. The roles of the speech-language therapist and audiologist in neonatal nurseries were discussed. The discussion emphasised that these roles are challenged by various factors in the South African context.

Chapter 2 provided a theoretical underpinning for the compilation of a neonatal communication intervention tool based on current literature in the field of neonatal communication intervention. Neonatal communication intervention tools and programmes currently used in South Africa were described. Different programmes from various disciplines, and those developed by speech-language therapists for neonatal communication intervention, are implemented to improve neonatal care in South Africa. The country-wide initiative to implement the evidence-based technique of KMC

(Pattinson et al., 2006; Dippenaar et al., 2006; Hann et al., 1999; Van Rooyen et al., 2002) indicates that speech-language therapists should recognise its importance and develop communication based materials and tools to complement this successful neonatal intervention. It was argued that a neonatal communication intervention tool for use by speech-language therapists and audiologists would contribute to managing certain challenges in the local context such as limited literacy of caregivers, multilingual and multicultural populations and limited materials and equipment.

Chapter 3 provided a detailed description of the methodology that was used to execute the research. The research was conducted in two phases and was discussed accordingly. The research aim and objectives, research design, participants, materials, data collection and analysis were provided.

Issues relating to ethics, reliability, validity and trustworthiness were also discussed.

In Chapter 4 the results of the study were displayed and described. The results from Phase 1 reflected that speech-language therapists and audiologists were performing a variety of roles. Some roles such as video-

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Chapter 5 fluoroscopic studies and hearing screenings were performed the least.

Participants expressed a need for assessment and screening equipment, culturally sensitive and user-friendly tools and materials for intervention, time management, counselling methods, more specialised team members, timely referrals, access to interpreters, access to CPD activities and resources.

Many participants did not have tools for parent guidance on the topics of the

neonatal nursery environment, paediatric dysphagia and feeding therapy,

over-stimulation and the infant’s stress cues and developmental care. These results were used to determine and select the nature and content of the tool/materials designed during phase two. Phase 2 comprised the selection of a specific need, the compilation of a developmental care programme for parents based on the need identified and a pilot study of the resulting programme.

Chapter 5 aimed to integrate the findings and draw conclusions on which clinical and research recommendations can be based.

5.3 GENERAL CONCLUSIONS

The following conclusions were drawn based on the results obtained from this research:

The overall aim of this study, namely to compile a locally relevant neonatal communication intervention instrument/tool for use by speech-language therapists in the neonatal nurseries of public hospitals, was achieved. Based on the results of the survey in Phase

1, as well as ECI literature a tool namely “Neonatal communication

intervention programme for parents” was compiled during Phase 2.

Objective 1: Speech-language therapists and audiologists in this study were performing varied and complex roles in neonatal nurseries.

Contextual challenges, such as language differences, limited supervision by experienced speech-language therapists, limited tools

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Chapter 5 and equipment for assessment and intervention influenced their service delivery in neonatal nurseries.

Objective 2: Most speech-language therapists and audiologists in the study required tools/materials specifically for use during parent education and staff/team training. It appeared that participants would have fulfilled certain roles, had they been equipped with the appropriate tools/materials. Although a need for further tools was identified it was encouraging that participants were using the few tools that were available to them.

Objective 3: A specific tool was selected to reflect the needs of the speech-language therapist participants in this study.

Objective 4: The resulting tool/material namely ‘Neonatal

communication intervention programme for parents’ was compiled according to current ECI literature. The programme consisted of a package with different training aids including a PowerPoint presentation and parent handout in English and IsiZulu, complied with the principles of adult learning.

Objective 5: The resulting programme was pilot tested and it was found to be useful in service delivery in a neonatal nursery. However, certain recommendations were made regarding the language and terminology, content and the length of the programme in order to make it more user-friendly and improve the overall quality thereof.

5.4 IMPLICATIONS OF THE RESEARCH

Clinical and theoretical implications of the research are depicted in Figure 5.1.

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Chapter 5

Figure 5.1: Implications of the research

The current research identified and attempted to fulfil in a need expressed by speech-language therapists and audiologists. The study managed to achieve the aim of compiling a programme for speech-language therapists for use with parents and caregivers in the neonatal nurseries in South African provincial hospitals. The programme was deemed appropriate in content and

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Chapter 5 judged to be user-friendly for the context by speech-language therapists in a pilot study.

This study highlighted the role of the speech-language therapist and audiologist in terms of prevention of communication delays and disorders.

Prevention of communication disorders is a primary professional responsibility of the speech-language therapist and audiologist (ASHA, 1991:16; Hugo,

2004:7). Children in South Africa are at an increased risk for communication disorders due to higher prevalence of low birthweight, Down syndrome, cleft lip and palate, cerebral palsy, fetal alcohol syndrome, HIV/AIDS, multilingualism, poverty and hearing loss (Kritzinger, 2000:13; Popich et al.,

2006:676; Swanepoel, 2004:290), which increases the need for prevention and adequate ECI services. This research is an example for speechlanguage therapists and audiologists in the public health sector on how to use adult education principles in parent training to prevent communication delays and disorders in infants.

The programme could also be used for raising awareness of ECI services within a certain community. Marketing and advocacy is a very important professional responsibility the speech-language therapist assumes (Billeaud,

2003:221; Rossetti, 2001:174). Using media for marketing aimed at the public can increase public awareness by reaching a wider audience (Thomas,

1993:46).

Marketing ECI services among health care workers can yield increased referrals from professional colleagues, increased visibility of speech-language therapy services in the community and improved use of services for infants and toddlers at risk for communication disorders (Billeaud,

2003:221). South Africa has an increased prevalence of infants at risk for communication disorders (Kritzinger, 2000:13) and therefore marketing of ECI among the general public, as well as health care workers, should be a priority of local speech-language therapists working in the public health sector.

According to ASHA (2008 [a]) ECI services must promote children’s participation in natural environments, which include community settings outside of the home environment where children without disabilities

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Chapter 5 participate. Community work increases the existing professional knowledge on diverse communities within South Africa, which presents therapists with the opportunity to implement prevention programmes such as adult training

(Popich, 2003:23). This study emphasised involvement in community work

and not only in the lives of individual families. The research could be used as an example of caregiver training within a specific community in order to reach more infants and toddlers in need of ECI services and to improve the current services in communities.

This study highlighted information on the roles of speech-language therapists

and audiologists in the neonatal care of high risk infants in the public health

sector. SASLHA compiled guidelines for ECI (Louw, 1997), but currently there are no guidelines for early intervention in the NICU in South Africa.

Guidelines by ASHA (2005) are being used although contextual differences hinder the direct application thereof. This research gathered valuable information regarding the roles and responsibilities of speech-language therapists and audiologists in local NICU, neonatal high care and KMC nurseries. It can therefore be used to guide future attempts to compile local guidelines for speech-language therapists in the NICU.

The “Neonatal communication intervention programme for parents” is compared to the ASHA (2008 [a]) principles in Table 5.2. According to ASHA

(2008:10 – 17 [a]) the following guiding principles constitute best practice for early and effective communication interventions:

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Table 5.2: Comparison of ASHA’s guiding principles (2008 [a]) and the

“Neonatal communication intervention programme for parents”

Guiding principle (ASHA, 2008)

[a]

1) Services are family-centered and culturally and linguistically responsive.

‘Neonatal communication intervention programme for parents’

The programme was compiled for speechlanguage therapists working with parents and families. The programme focused on involving the family, rather than only the infant, during intervention. The programme consisted of a parent handout that was available in two languages and incorporated many photos and images reflecting the diversity of parents with their infants in South Africa. The programme attempted to be culturally and linguistically sensitive.

2) Services are developmentally supportive and promote children’s participation in their natural environments.

The programme aimed to provide speechlanguage therapists with materials to guide parents in developmentally supportive interaction and appropriate stimulation of their premature infants.

Neonatal nurseries become closer to natural environments when the infant’s parents are involved in the treatment.

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Table 5.1 continued: Comparison of ASHA’s guiding principles (2008

[a]) and the “Neonatal communication intervention programme for parents”

Guiding principle (ASHA, 2008)

[a]

3) Services are comprehensive, coordinated and team-based.

4) Services are based on the highest quality evidence that is available.

‘Neonatal communication intervention programme for parents’

The programme covered the topic of

‘developmental care’. The information presented was comprehensive. The programme is intended for speechlanguage therapists who provide neonatal intervention within a transdisciplinary team approach. The programme should be coordinated with medical, nursing and other services rendered to infants and mothers in the nursery.

The programme had a strong theoretical underpinning and was compiled from a comprehensive review of recent neonatal care and ECI literature. The programme is based on needs identified in the survey in Phase 1.

According to Table 5.2 the study complied with the guiding principles for best practice in ECI (ASHA, 2008 [a]) and therefore contributed to neonatal care of

high risk infants in South Africa.

5.5 CRITICAL REVIEW

A critical review of the research is necessary for the researcher to reflect on the extent that the research aims were achieved during this study. A discussion of the strengths and limitations is important as it may guide future researchers to use or avoid similar aspects during research. The two phases are discussed separately.

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Chapter 5

5.5.1 Critical review of Phase 1

The strengths and limitations of Phase 1 are depicted in Figure 5.2.

- Questionnaire obtained valuable information regarding roles of SLT & A in neonatal nursery in SA context

- Identified needs of SLT & A

Strengths

- Poor response from DoH and participants

- Questionnaire: editing

- Limited number of participants, specifically audiologists

Limitations

Phase 1

Figure 5.2: Strengths and limitations of Phase 1

Strengths

The value of the questionnaire in gathering information on the roles of speech-language therapists and audiologists in the neonatal nursery in South

Africa: A strength of this research is that it obtained information regarding the roles of the speech-language therapist and audiologist in the neonatal nursery in South African provincial hospitals that was previously unknown. A dearth of information exists regarding the role of the speech-language therapist in the NICU in South Africa (De Beer, 2003:2). Currently there are no guidelines available for speech-language therapists working in the NICU in South Africa, but international literature provides guidelines for service delivery in the NICU in the USA (ASHA, 2005). The results of phase one provides valuable information for the future compilation of service delivery guidelines for speech-language therapists and audiologists in the NICU in South Africa.

Identified needs of speech-language therapists and audiologists: A strength of this study is that the results determined the needs of a group of speechlanguage therapists and audiologists working in provincial hospitals’ neonatal nurseries. It not only determined the need for tools and materials, but also identified needs for more accessible CPD activities, resources, interpreters and more qualified professionals e.g. audiologists and paediatricians.

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Limitations

Poor response from the Department of Health: A limitation of this study was that only six of the nine Departments of Health responded to the request for permission to conduct the research. The results were drawn from only six provinces in South Africa, which implies that the results could not be generalised to speech-language therapists and audiologists country-wide.

Editing of the questionnaire: Certain questions in the questionnaire could have been worded differently to yield results, which would have been easier to analyse statistically e.g. question B5 enquired about the percentage of time the participants spent in the NICU, NHCU and KMC wards. Many participants answered the question inappropriately by providing a number of hours, minutes or visits per day. This question may have yielded more accurate information if participants were presented with a Likert scale with five options to choose from. According to Leedy and Ormrod (2001:192) a survey must be scrutinised repeatedly to make sure that it addresses the researcher’s needs. The questionnaire was, however, pilot tested in advance, which revealed no problems with the wording of any questions. The questionnaire was therefore deemed appropriate to conduct the study.

Limited number of participants, specifically audiologists: A limitation of the research was that there were a limited number of participants for this study.

Only two audiologists participated in the study. This could be due to the fact that the questionnaire entailed neonatal communication intervention, which is a specialist field of speech-language therapy. When received at the hospitals, the questionnaire was subsequently rather offered to the speechlanguage therapists than to the audiologists to complete. Limited information was obtained about the needs of audiologists in the neonatal nursery. The selection of the nature and content of the tool was therefore largely based on the perceptions of speech-language therapists, which resulted in a programme for parents on developmental care to be used by speechlanguage therapists. The researcher repeatedly made telephonic contact with participants in order to increase the return rate of the questionnaire. After the

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Chapter 5 third telephonic contact, no further contact was made as participation to the study had to be voluntary.

5.5.2. Critical review of Phase 2

The strengths and limitations of Phase 2 are depicted in Figure 5.3.

Figure 5.3: Strengths and limitations of Phase 2

Strengths

Tool addressed a need: The compilation of the programme titled “Neonatal

communication intervention programme for parents” attempted to address a need identified by speech-language therapists in Phase 1. The principles of adult learning were adhered to during the compilation of the programme. This increases the probability that the programme would be used in adult training

(Popich, 2003:19), which would improve ECI services in public hospitals.

Theoretical underpinning: The programme was compiled with a strong theoretical underpinning that contributed to its trustworthiness. The programme’s content was accurately described (De Vos et al., 2005:346), which enhanced the credibility thereof. Speech-language therapists and audiologists must consistently seek out new information to improve therapeutic effectiveness as they are responsible to provide services that are research-based (Bernstein-Ratner, 2006:257; ASHA, 2005:12).

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Accommodated parents with different levels of literacy in two languages: A strength of the research is that the programme attempted to accommodate parents with different levels of literacy by providing a handout with photos and images depicting key concepts with corresponding blocks for responses to be marked with and /x/ or /

3

/. The programme is easy to use as it has materials and strategies that were designed to save time and facilitate the presentation thereof. Graphic materials such as handouts assist speech-language therapists and audiologists to be culturally sensitive when working with parents and caregivers (Louw & Avenant, 2002:150). The handouts were available in both English and IsiZulu, which is viewed as both a strength as well as a limitation, as material is also required in the nine other official languages of South Africa.

Limitations

Only pilot tested by a limited number of participants: The programme was pilot tested by only three participants working in a provincial hospital, which is at least the intended context for the programme. This limits the use of the programme as the researcher can not be sure that the programme met the needs expressed by all participants. While it was necessary to pre-test the preliminary programme, the objective was not to validate the programme during this study.

Therefore three participants were deemed adequate for the pilot study. It would be valuable to validate the programme in further research using a larger group of speech-language therapists.

Translation of handout: The handout was translated into IsiZulu from English in order to accommodate parents who are not proficient in English. A limitation was that the programme was made available only in two of the eleven official languages namely English and IsiZulu. Culturally appropriate educational and counselling opportunities should be provided to families in the neonatal nursery in provincial hospitals (Rakau, 2005:42). Therefore the application of the programme across different cultural groups is limited.

Based on this discussion, certain recommendations for research were made.

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5.6 RECOMMENDATIONS FOR FURTHER RESEARCH

An answered research question leads to a multitude of new research questions to be answered (Swanepoel, 2004:297).

Therefore the following recommendations for further research were conceptualised from the current study:

This study’s results highlighted a need for research on various applicable

formats of the parent guidance programme that was compiled during this research. It could be possible to produce a DVD format of this programme in order to make it more user-friendly for speech-language therapists who have large caseloads and little time to present the programme.

It would be useful to obtain the perceptions of a larger group of speech-

language therapists and audiologists in a survey regarding their roles and needs within the local neonatal nursery context. Further research is needed regarding the needs of speech-language therapists in local public hospitals to draw conclusions and generalise the results to a larger community. It may also be valuable to incorporate more experienced therapists into such a survey as their insight into their needs may differ from less experienced therapists. Private speech-language therapists should also be involved in such a survey. It may be valuable to conduct a separate survey to identify perceptions of audiologists.

Although neonatal communication intervention is a specialised field of service delivery, most of the participants in the current study were inexperienced. Research is needed in terms of the knowledge and skills

of community service speech-language therapists regarding neonatal

communication intervention. This will enable tertiary institutions in South

Africa to adapt and enrich their undergraduate ECI curricula in order to prepare future speech-language therapists more effectively.

The parent guidance programme was only pilot tested by three speechlanguage therapists. Research on a larger population is therefore

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Chapter 5 necessary to validate the use of this programme across different communities in South Africa.

Another recommendation is to evaluate the effectiveness of the

programme on mothers’ interaction skills with their infants. Speechlanguage therapists need to demonstrate that their intervention efforts have and effect (Kritzinger, 2007). According to Plante (2004:389) professional reliance on evidence-based practices sets a verifiable standard for what constitutes an acceptable procedure in a field. By evaluating the programme’s effectiveness, evidence-based practice is followed.

It would be valuable to determine whether the programme meets the

mothers’ needs for information and training. Families need information on child health and development (Kritzinger, 2007) and therefore it may be useful to establish whether this programme fulfils in the parents’ needs.

Translating the programme to the other official languages in South Africa should be explored. If the programme is translated into the other nine official languages namely IsiXhosa, Afrikaans, SePedi, SeTswana,

SeSotho, XiTsonga, SiSwati, TshiVenda and IsiNdebele it will be useful to more speech-language therapists across a wider geographical area.

Consequently the programme will be more culturally sensitive and the range of applicability will be increased.

As previously mentioned, the use of surveys as research material should possibly be incorporated into undergraduate training and undergraduate research for speech-language therapists and audiologists. Speechlanguage therapists and audiologists can become confident in the use of surveys as data-collection instrument on an undergraduate level. This may lead to enhanced quality of research in the field of Communication

Pathology.

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5.7 FINAL COMMENTS IN CONCLUSION

The increased prevalence of infants at risk for communication disorders in

South Africa (Kritzinger, 2000:13) necessitates early interventionists to become involved in clinical and research efforts in developing ECI services for provincial hospitals. Speech-language therapists and audiologists not only have an essential role to fulfil in neonatal nurseries, but also have an ethical responsibility to develop creative solutions for challenges arising from service delivery in the South African public health context. Speech-language therapists and audiologists must contribute to neonatal care of high risk infants to improve infants’ chances of survival and facilitate optimal development.

“Attainment of each child’s full potential, irrespective of culture or language, is the proverbial pot of gold at the end of the rainbow.”

- Carolyn C. Madding (2000:17) -

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Swanepoel, D., Delport, S.D. & Swart, J.G. 2004. Universal newborn hearing screening in South Africa – a First World dream? South African

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Theunissen, M. & Swanepoel, D. 2008. Early hearing detection and intervention services in the public health sector in South Africa.

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Thomas, M. 1993. Making media work for you. ASHA, 35 (8), 46 – 47.

Thompson, T. 1992. Developmental Risk Factors and Poverty. In T.

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Uys, K.J. 2000. Oral feeding skills of premature infants. Unpublished

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VandenBerg, K.A. 2007. Individualized developmental care for high risk newborns in the NICU: A practice guideline. Journal of Early Human

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Van Jaarsveld, M.E. 2004. Verpleegkundiges se persepsies van

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187

APPENDIX A [ i ] – Ethical clearance

Appendix A

APPENDIX A [ ii ] – Permission from provincial departments of health

Appendix A

Appendix A

Appendix A

Appendix A

Appendix A

Appendix A

APPENDIX B – Letter to departments of health

Appendix B

Department of Communication Pathology

Speech, Voice and Hearing Clinic

Tel : +27 12 420 2355

Fax : +27 12 420 3517

Email : [email protected]

14 May 2007

Dear Sir/Madam,

PERMISSION TO REQUEST SPEECH-LANGUAGE THERAPISTS AND

AUDIOLOGISTS IN THE PROVINCE TO ACT AS RESPONDENTS IN A RESEARCH

PROJECT

As part of a Masters degree in Communication Pathology at the University of

Pretoria, I am conducting a research project involving speech-language therapists and audiologists working in provincial hospitals. The research project aims to compile an Early Communication Intervention instrument/tool for speech-language therapists and audiologists to use in the Neonatal Intensive

Care Unit (NICU) and Neonatal High Care Unit (NHCU) of provincial hospitals.

The role of the speech-language therapist in provincial hospitals in South Africa is not widely described and there is believed to be a need for culturally appropriate and user-friendly clinical instruments as well as materials for training of other professions working together with the speech-language therapist in this context. The information in this survey will determine whether such a need exists and if so, an attempt will be made to compile/develop an instrument/tool for clinical use in the NICU and NHCU.

The role of the speech-language therapist in this specific context will also be described in order to determine what therapists are currently using and what is working for them. These professionals’ opinions are important and will have a direct influence on whether an instrument/tool will be compiled, what the content would be and in what manner it will be presented.

Appendix B

In order to conduct this study I will require the participation of speechlanguage therapists and audiologists who are currently providing Early

Communication Intervention in provincial hospitals. They will be requested to complete a questionnaire. A copy of the questionnaire will be made available to you should you so require. Personal information of the respondents as

well as the identity of their institution will be kept confidential. The data will be stored for a period of 15 years in accordance with international guidelines. The results of the study may be used for publication resulting from the Master’s Thesis.

I would appreciate your permission to approach the speech-language therapists and audiologists working in provincial hospitals in your province to act as respondents for the above research project. I look forward to hearing from you as soon as possible due to time constraints involved. You may contact me at the facsimile number and e-mail address below.

Sincerely

______________________________

Esedra Strasheim

Researcher

Email: [email protected]

Facsimile: 086 613 0625

______________________________

Prof B. Louw

Research Supervisor

Head: Department of Communication Pathology

APPENDIX C – Cover letter to participants

Appendix C

Department of Communication Pathology

Speech, Voice and Hearing Clinic

Tel

Fax

: +27 12 420 2355

: +27 12 420 3517

Email : [email protected]

20 October 2007

Dear Speech-language therapist

The compilation of a preliminary instrument/tool for speech-language therapists in Neonatal Care Units of public hospitals

You are requested to participate in a survey as part of a Master’s Degree in

Communication Pathology at the Department of Communication Pathology,

University of Pretoria that aims to compile a clinical Early Communication

Intervention instrument/tool for speech-language therapists to use in the

Neonatal Intensive Care Unit (NICU) and Neonatal High Care Unit (NHCU) and/or the Kangaroo Mother Care Unit of provincial hospitals.

The role of the speech-language therapist in the NICU and NHCU in provincial hospitals in South Africa is not widely described and there is believed to be a need for culturally appropriate and user-friendly assessment and treatment instruments as well as materials for training of other professions working together with the speech-language therapist in this context. The information in this questionnaire will determine whether such a need exists and if so, an attempt will be made to compile/develop an instrument/tool for clinical use in the NICU, NHCU and KMC unit. The role of the speech-language therapist in this specific context will also be described in order to determine what therapists are currently using and what is working for them. Your opinion as a professional is very important and will have a direct influence on whether an instrument/tool will be compiled, what the content would be and in what manner it will be presented.

By completing the questionnaire you are providing informed consent to take part in the study. You will be assigned a number and your identity, the identity of your institution as well as your answers will be handled

Appendix C

confidentially. If at any stage you feel that you do not longer want to

participate, you are free to withdraw. The data will be stored for a period of

15 years in accordance with international guidelines. The results of the study may be used for publication resulting from the Master’s Thesis.

Please complete the survey and send it back via e-mail or facsimile to the contact details below. If you have any questions regarding the study, you are welcome to contact the researcher at 082 461 72 48.

Thank you for your willingness to participate in this research project and the time you spent despite a busy schedule.

______________________________

Esedra Strasheim

Researcher

Email: [email protected]

Facsimile: 086 613 0625

______________________________

Prof B. Louw

Research Supervisor

Head: Department of Communication Pathology

Appendix D

APPENDIX D – Questionnaire

Perceptions of Speech-language therapists providing ECI in Neonatal Care

Units in public hospitals

Esedra Strasheim

Department of Communication Pathology

University of Pretoria

RESPONDENT NUMBER:

SECTION A

A1. What is your professional qualification?

Speech-language Therapist

Speech-language Therapist and Audiologist

Audiologist

A2. What are you currently practicing as?

Speech-language Therapist

Speech-language Therapist and Audiologist

Audiologist

A3. What is your highest qualification obtained?

Bachelors degree

Masters degree

Doctorate

A4. Where did you obtain this qualification?

_____________________________________

A5. In which year did you obtain this qualification?

_____________________________________

A6. In which province are you currently employed?

Eastern Cape

Free State

Gauteng

Kwazulu Natal

Limpopo

Mpumalanga

Northern Cape

Northwest

Western Cape

A7. What are your current work contexts?

(Please indicate all applicable contexts)

YES NO

Community Health Centres/Outreach Clinics

District/Regional Hospital

Tertiary/Academic hospital

OTHER (Please specify)

A8. How many years of experience do you have in the public hospital context?

________________________________________________

For office use:

V1

V2

V3

V4

V5

V6

V7

V8

V9

V10

V11

V12

Appendix D

A9. How many employees are in your department? (Please fill in the appropriate number):

Permanent speech-language therapists

Permanent speech-language therapists & audiologists (dual qualified)

Permanent audiologists

Community service therapists (for speechlanguage therapy and/or audiology)

Trained interpreters and/or assistants

SECTION B

B1. How often do you personally provide Early Communication Intervention (ECI) to infants and young children within your caseload?

Most of the time Sometimes Rarely Unsure

B2. Does the hospital where you are employed have the following? (Please mark all applicable

options):

Neonatal Intensive Care Unit

Neonatal High Care Unit/Ward

YES NO

Kangaroo Mother Care Unit/Ward

Paediatric Medical Ward

Paediatric Out Patient Department

B3. What is your department’s current system with regard to work allocation and responsibilities? a) We have permanently assigned wards and clinics. b) We rotate between wards and clinics within the department. c) We/I have no specific system. d) Other – please elaborate.

B4. Do you personally provide ECI in any of the following? (Please mark all applicable

options):

Neonatal Intensive Care Unit (NICU)

Neonatal High Care Unit (NHCU)

YES NO

Kangaroo Mother Care Unit (KMC)

B5. Please indicate what percentage of time you estimate you spend in the following wards in a week:

NICU

NHCU

KMC

B6. Do you enjoy your work in the NICU/NHCU/KMC?

Very much A little bit Not at all

B7. What do you enjoy about working in this context? (Please describe)

V13

V14

V15

V16

V17

V18

V19

V20

V21

V22

V23

V24

V25

V26

V27

V28

V29

V30

V31

V32

V33

V34

Appendix D

B8. What don’t you enjoy about working in this context?

B9. Do you feel competent working in this context?

Most of the time

Sometimes Rarely Never

B10. What do you attribute your answer in question 9 to?

YES NO

Undergraduate training

Post graduate studies

Years of experience in this context

Regular in-service training sessions

Advanced training courses in the field

OTHER (Please specify)

V35

V36

V37

V38

V39

V40

V41

V42

V43

V44

V45

B11. When working in the following contexts, do you perform any of the following? (Please

mark all the applicable options)

Assessment of feeding regarding sucking and swallowing.

NICU NHCU KMC

V46

Utilizing video-fluoroscopic studies for assessment of swallowing disorders.

V47

V48

Assessment of communication development.

Assessment of mother-child-communication-interaction.

V49

V50

V51

Intervention for feeding problems in the form of direct treatment with child (e.g. oral-facial stimulation for promotion of sucking).

V52

V53

Intervention for feeding problems and prevention of communication delays in the form of parent guidance.

V54

V55

V56

Application of Developmentally Appropriate Care (Light- and noise reduction, positioning and handling of infant).

Encouragement/promotion of full-time or intermittent

Kangaroo Mother Care.

Consultation with other professions in a multi- or transdisciplinary team.

V57

V58

V59

V60

V61

Attendance of ward rounds with other professions.

Discharge planning and planning of follow-up treatment/management programmes after infant is discharged.

In-service training and guidance of staff/team members.

Informing parents, family members and caregivers of child’s condition, progress and future expectations.

Counselling and support of parents, family members and caregivers.

Hearing screening

Other (please add anything which was not mentioned):

B12. Do you feel that you are providing a good service in this context? What do you attribute this to? (Please describe)

V62

V63

V64

Appendix D

SECTION C

C1. If you could change anything about your work in this context, what would you like to change?

Number and type of referrals from other professionals

Screening methods and/or equipment/materials

Assessment methods and/or equipment/materials

Treatment methods and/or equipment/materials

Counselling methods

Team members (more/fewer team members, different specialization, assistants/interpreters)

Time management

V65

V66

V67

V68

V69

V70

V71

V72

V73

V74

V75

Resources (literature, communication with experts)

In-service training in your hospital or province

Continued Professional Development (CPD)

OTHER (Please elaborate)

C2. What are your perceptions and opinions regarding culturally relevant instruments, materials and/or tools for use in your work context? (Please describe)

C3. What are your perceptions and opinions regarding user-friendly instruments, materials and/or tools for use in your work context? (Please describe)

SECTION D

V76

V77

V78

V79

V80

V81

D1. Are there any assessment instruments or assessment materials in the following assessment areas available to you for use in the NICU/NHCU/KMC?

YES, YES, NO, but I NO, and I UNSURE and I use it but I don’t use it would like to have it don’t think it’s necessary

Neonate’s communication development.

Feeding.

Mother-child interaction.

NICU/NHCU environment.

Other (Please add anything which was not mentioned)

V82

V83

V84

V85

V86

Appendix D

YES, and I use it

YES, but

I don’t use it

NO, but I would like to have it

D2. Are there any materials and tools for parent guidance on the following topics available to you for use in the NICU/NHCU/KMC?

NO, and I don’t think it’s necessary

UNSURE

Normal communication development and the neonate’s current capabilities.

NICU/NHCU environment and the staff members.

Paediatric Dysphagia and

Feeding therapy.

Over-stimulation, identification of infant’s stress behaviours.

Developmentally

Appropriate Care

(Positioning, handling, light- and noise management).

Kangaroo Mother Care.

Communication interaction with the infant.

Developmental milestones and follow-up services after discharge from hospital.

Other (Please add anything which was not mentioned)

D3. Are there any materials and tools for training of staff members on the following topics available to you for use in the NICU/NHCU/KMC?

YES, and I use it

YES, but I don’t use it

NO, but I would like to have it

NO, and I don’t think it’s necessary

Developmentally Appropriate Care

(positioning, handling, light- and noise management).

Kangaroo Mother Care and ECI.

Role of the Speech-language therapist in neonatal care wards.

Other (Please add anything which was not mentioned)

D4. What are your suggestions or needs regarding tools for this working context?

UNSURE

D5. Please provide any additional comments regarding your work or your needs in this context:

Thank you kindly for your time.

Please return to: 0866130625

V100

V101

V102

V103

V104

V105

V106

V107

V108

V109

V87

V88

V89

V90

V91

V92

V93

V94

V95

V96

V97

V98

V99

Appendix E

APPENDIX E – Pilot study questionnaire Phase 1

Checklist for Pilot Study of Questionnaire:

Perceptions of speech-language therapists working in Neonatal Intensive

Care Units and High Care Units in provincial hospitals

Please indicate your answer by placing a tick ( and/or providing comments.

3

) in the appropriate block

Section A: Biographical

Information

Section B: Service delivery

Section C: Needs

Section D: The need for a tool

Overall format of questionnaire

Wording of questions

Good Adequate Needs improvement

Comments

Ordering of questions

Length of questionnaire

Physical appearance of questionnaire

What enhancements you would prefer before using the questionnaire again?

Appendix F

APPENDIX F – List of variables

Variable number Variable description

V37

V38

Enjoyment of work

Competence in work

Reasons for competence:

V39

V40

V41

V42

Undergraduate training

Post graduate training

Years of experience in this context

Regular in-service training

V43 Advanced training courses in the field

Roles in the NICU, NHCU and KMC ward:

V46

V47

V48

V49

V50

V51

Assessment of feeding

Assessment of feeding using video-fluoroscopy

Assessment of communication development

Assessment of mother-child-communication-interaction

Intervention for feeding problems using direct treatment with infant

(e.g. oral-facial stimulation for promotion of sucking)

Intervention for feeding problems and prevention of communication delays in the form of parent guidance

V52

V53

V54

V55

V56

V57

V58

Application of developmental care

Encouragement/promotion of full-time or intermittent

Consultation with other professions

Attendance of ward rounds with other professions

Discharge planning and planning of follow-up treatment/management programmes after infant is discharged

In-service training and guidance of staff/team members

Informing parents, family members and caregivers of child’s condition, progress and future expectations

V59

V60

V65

Counselling and support of parents, family members and caregivers

Hearing screening

Number and type of referrals

Possible future improvements:

V66

V67

Screening methods and/or equipment/materials

Assessment methods and/or equipment/materials

V68

V69

V70

V71

V72

V73

V74

Treatment methods and/or equipment/materials

Counselling methods

Team members (more/fewer team members, different specialization, assistants/Interpreters)

Time management

Resources (Literature, communication with experts)

In-service training in your hospital or province

Continued Professional Development

Needs in terms of assessment instruments/materials:

V82

V83

V84

V85

Neonate’s communication development

Feeding

Mother-child interaction

NICU/NHCU environment

Needs in terms of tools/materials for parent guidance:

Appendix F

V87

V88

V89

V90

Normal communication development and neonate’s current capabilities

NICU/NHCU environment and staff members

Paediatric dysphagia and feeding therapy

Over-stimulation, identification of infant’s stress behaviours

V91

V92

V93

V94

Developmental Care

Kangaroo Mother Care

Communication Interaction with the infant

Developmental Milestones and follow-up services after discharge from hospital

Needs in terms of tools/materials for staff/team training:

V100

V101

V102

Developmental Care

Kangaroo mother care and ECI

Role of the Speech-language therapist in neonatal nurseries

Roles in the NICU, NHCU and KMC ward:

VV46

VV47

VV48

VV49

VV50

VV51

VV52

Assessment of feeding - One hit across any context (NICU, NHCU or KMC)

Assessment of feeding using video-fluoroscopy - One hit across any context (NICU, NHCU or KMC)

Assessment of communication development - One hit across any context

(NICU, NHCU or KMC)

Assessment of mother-child-communication-interaction - One hit across any context (NICU, NHCU or KMC)

Intervention for feeding problems using direct treatment with infant

(e.g. oral-facial stimulation for promotion of sucking) - One hit across any context (NICU, NHCU or KMC)

Intervention for feeding problems and prevention of communication delays in the form of parent guidance - One hit across any context

(NICU, NHCU or KMC)

Application of developmental care - One hit across any context (NICU,

NHCU or KMC)

VV53

VV54

VV55

VV56

VV57

VV58

VV59

VV60

Encouragement/promotion of full-time or intermittent KMC - One hit across any context (NICU, NHCU or KMC)

Consultation with other professions - One hit across any context (NICU,

NHCU or KMC)

Attendance of ward rounds with other professions -One hit across any context (NICU, NHCU or KMC)

Discharge planning and planning of follow-up treatment/management programmes after infant is discharged - One hit across any context

(NICU, NHCU or KMC)

In-service training and guidance of staff/team members - One hit across any context (NICU, NHCU or KMC)

Informing parents, family members and caregivers of child’s condition, progress and future expectations - One hit across any context (NICU,

NHCU or KMC)

Counselling and support of parents, family members and caregivers -

One hit across any context (NICU, NHCU or KMC)

Hearing screening - One hit across any context (NICU, NHCU or KMC)

Neonatal Communication

Intervention Programme for

Parents

Esedra Strasheim

M.Communication Pathology

University of Pretoria

2009

Neonatal communication intervention programme for parents

Contents

1.

Guidelines to the presenter

2.

Aims and outcomes of programme

3.

Introduction and warm-up

Warm-up activity

What is a preterm baby?

Why does my preterm baby need special care?

How can prematurity affect listening and talking?

What is developmental care?

Why is developmental care important?

4.

Understanding my baby’s behaviour

Can my preterm baby hear me and see me? (hearing, sight and touch systems that form the building blocks for communication development)

What are my preterm baby’s stress signals?

When does my preterm baby show stress signals? (light, noise, handling)

What is self-regulatory behaviour?

5.

What should I do to help my baby develop?

What can I do when my preterm baby shows stress signals? (calming techniques, positioning, environmental adaptations)

What is kangaroo mother care?

How do I communicate with my preterm baby?

Feeding my preterm baby

6.

Conclusion and reflection

Why is it important that my preterm baby is followed up regularly?

What should I do when I am concerned about my preterm baby?

Time for reflection and questions

7.

References

1. Guidelines to the presenter

This programme is intended for use by speech-language therapists with parents and caregivers whose infants are hospitalised in the NICU, neonatal high care ward or KMC ward at provincial hospitals in South Africa.

You, as a speech-language therapist, are requested to present the programme as part of your treatment in the NICU, neonatal high care ward or KMC ward at your hospital with a small group of parents/caregivers (four to five) whose infants are in the neonatal nursery.

You may select the venue for the programme to be presented.

The programme provided to you contains the following:

9 One hard copy of the complete programme to guide you when presenting the information to the parents.

9

One powerpoint™ presentation of the programme on a CD to use when presenting the programme.

9

One set of powerpoint™ slides printed on transparencies.

9

Handouts to be provided to the parents in either English or isiZulu.

You may use either the powerpoint™ presentation on the CD or the transparencies if you are not equipped with a lap-top computer and data projector.

The services of an interpreter may be useful if you have access to such services.

It would be useful to find out about the parents’ levels of literacy before starting with the programme.

You are requested to use the handouts regardless of the parents’ literacy levels.

The handouts encourage the parents to participate actively. It is designed in such a way that icons and photos may guide parents who are not literate, but if they are unsure how to complete the task, they should be assisted.

Certain aspects of the programme need to be demonstrated. It may be useful to have a doll and a towel ready for demonstration.

Please provide the parents with contact details of the speech-language therapist and audiologist should they require follow-up services at your hospital.

2. Aims and outcomes of the programme

Aim

The aim of the tool is to provide speech-language therapists in local public hospitals with a tool to educate and guide parents/caregivers of infants in the neonatal nursery (the NICU, neonatal high care ward or KMC ward) on developmental care and early communication interaction and appropriate stimulation.

Outcomes

After completion of this programme, the parent or caregiver: should know what prematurity is, why preterm infants are treated differently from typical infants and that prematurity affects communication development should know what developmental care is and that it primes the infant for communication interaction should have knowledge about the infant’s capabilities (auditory system, tactile system, and visual system) and how these modalities are affected by prematurity should have knowledge about the infant’s behaviour (stress signals and selfregulatory behaviour) should be able to identify stressors in the infant’s environment (noise, light and handling) that can lead to distress of the infant should be able to provide calming techniques (positioning, swaddling, KMC and containment) when the infant is in distress should understand the benefit of kangaroo mother care as a method of providing developmental care should be able to provide responsive communication stimulation at the appropriate times should have knowledge about the relationship between feeding and communication development should have insight into the importance of follow-up services for the preterm infant’s development and more specifically communication development should know who to contact when in doubt about the infant’s general development and, more specifically, communication development and hearing.

3. Introduction and warm-up

Warm-up activity

Parents and professionals introduce themselves to the rest of the group.

Allow each parent to share with the others what the name of their baby is and when their baby was born. Ask mothers to comment on their experience in the neonatal nursery today or during the last week/month. The professional should also share a personal experience about the neonatal nursery or related topic to establish rapport with the parents.

Explain to the group that the presentation aims to guide them in communication stimulation and developmental care of their infants.

What is a preterm baby?

A preterm baby is a baby who was born too soon, more than one month before the due date. A preterm baby’s body and brain are still immature and not yet ready to cope with the stimulation from the NICU.

Why does my preterm baby need special care?

A baby who was born too soon needs special help to grow and learn. Some preterm babies need special help from a ventilator machine to breathe, while some babies need help with feeding, because they are not ready to suck from the breast.

Preterm babies become stressed or over-stimulated easily by too much noise or light, or too much movement, handling or touching. If babies become over-stimulated or stressed, it influences how they grow and learn. A preterm baby must have the correct medical care in the hospital and must be monitored regularly as they grow up.

How can prematurity affect listening and talking?

Anything that interferes with a baby’s normal interaction with their environment

(their mother, father and family) could affect their communication ability (listening and talking). Preterm babies are hospitalised and cannot have normal interaction with their mother and father, which can affect their learning.

Preterm babies may have more health problems such as chest infections or middle ear infections, which could lead to them learning more slowly than other children.

Preterm babies receive medicine when they are in the hospital, which can affect their ears (hearing loss). If babies do not have normal hearing, they will have difficulty to learn how to understand words and to talk.

Some babies need oxygen for a long time, which can affect their eyes (retinopathy of prematurity). If babies cannot see, it can affect how they learn to crawl or walk and use their hands.

Many preterm babies’ brains are not ready and have difficulty to make sense of the sensory information they get from the hospital staff during medical procedures or from their parents i.e. touch (tactile), movement (vestibular) and deep touch

(proprioception). This may affect how they tolerate movement or touch during play.

It can also influence how they tolerate light touch and deep touch later on when they start to eat hard, textured food. Therefore some preterm babies may have feeding problems when they are older, which may also lead to a communication problem if it is not treated when a baby is young.

What is developmental care?

Developmental care is a specific way of caring for the baby that helps the mother and father as well as the nurses to change the environment of the hospital room so that the baby will not become stressed or over-stimulated. Developmental care also helps the mother, father and nurses to understand what babies are trying to say to them when they are stressed.

Why is developmental care important?

The hospital environment causes preterm babies to become stressed and makes them cry. Babies are also separated from their mother. This interferes with the baby’s sleeping. Babies grow and learn best when they are sleeping.

Developmental care helps preterm babies to grow and develop the normal skills that are necessary in order to learn how to move, such as sitting and crawling, to play with their hands, to listen to people and understand them, to talk and to make friends.

In short: developmental care tries to copy the conditions in the womb to reduce stress and help the baby to grow and learn. Developmental care limits the noise and light and handling that prevent babies to learn from the environment and their parents. Therefore developmental care is important for the baby to learn to talk and to listen (communication development)!

4. Understanding my baby’s behaviour

Can my preterm baby hear me and see me?

(Assist the parents to mark whether their baby can hear or see in the handout on page 3)

The senses: We learn from the world through our senses, namely hearing (ears), seeing (eyes), taste (tongue), smell (nose) and touch (tactile). We also have two senses that we cannot see: balance and movement (vestibular) and deep touch that provides us with information on where our bodies are (proprioception). Your babies’ sensory systems grow while they are still in the womb. When they are awake, your babies can hear you when you talk to them. Preterm babies can also see and use their smell. Even though your babies were born too soon, they can feel your hands when you touch or hold them and smell you when you are close.

Monitoring development: The time in the hospital (NICU) can affect your baby’s senses. Preterm babies need special care while they are in the hospital to learn how to listen, see, touch, smell, taste and move so that they can learn in a normal way when they are grown-up. A baby’s hearing and seeing may be affected because of the medicine or oxygen given to save their life in hospital. If your babies have an ear or eye problem, it will affect their listening and talking. Therefore we have to monitor preterm babies closely as they grow and develop.

What are my preterm baby’s distress signals?

A preterm baby is not ready to cope with the outside world like a full-term baby.

Therefore preterm babies show certain signals to tell their parents that they are stressed or unhappy. Every preterm baby shows different signals to show that they are stressed.

Babies can show any of the following signals when they are stressed:

Changes in heart rate, blood pressure, breathing, oxygen saturation or skin colour.

Hiccupping, gagging/vomiting, sighing, yawning, sneezing, straining.

Tongue thrusting, frowning, making fists, sitting on air, finger splaying, grimacing or putting lips together, turning away or turning head, frantic movements.

Cannot stop crying, fussy, facial twitches.

Low-level alertness, easily over-stimulated, uncoordinated eye movements, looking away or closing eyes, wide open eyes with panicky or worried look.

(Assist the parents to mark the stress behaviours they have seen with their own baby on pages 4 and 5 of the handout).

When does my preterm baby show stress signals?

Preterm babies show stress signals when there is too much noise, light, touching or movement. Their immature body cannot cope with of all the stimulation at once. As

babies grow, they will gradually learn to deal with all the stimulation at once. The following aspects may cause your baby to show stress signals:

Noise: noise in the hospital can affect your baby’s ears and should be limited! The following may cause your baby to stress: too much and too loud talking or singing sudden loud sounds close to them telephones radio or television

Light: the constant light in the hospital may also affect your baby’s sleeping. The following may cause your baby to stress: bright lights of the hospital lying in the direct sunlight next to a window during the day

Touch or movement: your baby receives many painful procedures in the hospital because it is necessary to help your baby become healthy and stable. These procedures are stressful for your baby. The following may cause your baby to stress: moved too quickly turned over quickly rocking or bouncing light touching or stroking

(It may be helpful to demonstrate the above-mentioned stressors using the doll.

Assist the parents to mark off the reasons for over-stimulation by indicating an x or

3

on page 6 of the handout).

What is self-regulatory behaviour?

These are signals babies show to calm them or to recover from stress. All preterm babies calm themselves in their own way. These are some examples of the calming behaviours babies use: hand to mouth movement hand to face movement sucking grasping holding of their own hands finger grasping flexion position (curled up position bringing arms and legs close to the body)

Remember that stress is not good for your baby and can cause learning and developmental problems later on. That is why it is important to watch your babies to see why they are showing stress signals. You can help your baby to calm down by encouraging any self-regulating behaviour and changing the source of the stress (e.g. noise, light and handling). It will be helpful if you do KMC when your baby is stressed.

(Demonstrate the above-mentioned self-regulatory behaviour. Refer to page 7 in the handout for examples of self-regulating behaviour).

5. What should I do to help my baby develop?

What can I do when my preterm baby shows stress signals?

When your babies show stress signals, it means that they are not ready for the stimulation that you or the hospital are giving them and you should immediately change or stop what you are doing.

(Refer to page 8 of the handout for examples of what parents may do when their babies show stress).

Noise: when you have identified a problem with noise, ask the nurse or a therapist to help you to eliminate it. You can do the following to limit the noise in the room where your baby is sleeping: close the incubator’s doors softly so that there is no noise close the rubbish bins softly don’t place any bottles or cups on top of the incubators when the baby is inside don’t tap your hand or your fingers on the incubators talk or sing softly to your baby and stop when you see that they are not ready for it answer your cell phone immediately if it rings and talk softly or move outside the room call a nurse immediately if an alarm goes off by your baby’s incubator

Light: if you are worried about too much light in your baby’s incubator or crib, ask a nurse or a therapist to help you: you can cover your baby’s incubator with a blanket or a towel to shield them from the bright light. Remember to ask the nurse before you change anything hold your babies against your body covering them with a blanket in the KMC position

(Demonstrate the above-mentioned to the parents using the towel)

Touching or moving: stop stroking or moving the baby as soon as you see any stress signals or crying. if your babies are very ill or unstable, do not touch them too much. This will help your baby to become stable and grow faster do not tickle, bounce or pat your baby yet. Watch them carefully and use gentle but firm touch and slow movements when touching your baby when turning or picking up your baby, use slow, gentle but firm movements, that do not startle or scare them

(Demonstrate the above-mentioned to the parents using the doll)

Calming techniques: ask the nurses or therapists to help you position your baby in the incubator or crib when your baby is stable enough to handle: you can position your baby in flexion with arms and legs toward the midline close to the body (on his/her side or on his/her back)

use a rolled towel or blanket to create a nest for your baby. The nest should be snug and high enough for the baby to kick against if your baby is stable enough, ask the nurses or therapists to help you swaddle your baby in a blanket. Wrap babies tightly in a blanket so that their arms are toward the middle (possibly close to their mouth) and close to their body (in flexion). This position will help calm your baby so that you can talk to him/her and make eye contact use positive touch techniques such as containment holding/still touch by placing your hands firmly on their bodies to help calm them. You may also cup their heads in your one hand ask the nurses to assist you with kangaroo mother care

(Demonstrate the above-mentioned to the parents using the doll and the towel)

What is kangaroo mother care (KMC)?

(Refer to page 9 in the handout for examples of KMC)

Kangaroo position: the baby is dressed in a cap and a nappy. The baby is then positioned in a curled up, upright (flexion) position on their mother’s bare chest between the breasts with the baby’s head under the mother’s chin. This position is similar to when the baby was in the womb. The mother and baby are wrapped with a blanket or a special wrap to keep the baby in place.

(Demonstrate the above-mentioned to the parents using a doll)

Kangaroo mother care is a safe and cost-effective way of giving developmental care for your preterm baby. It gives the baby all the protection and stimulation that they need to learn and grow. KMC is ideal for frequent breast feeding. KMC can also be used when your baby shows stress behaviours as you are reducing the sound, light and touch the baby gets and imitating the feeling the baby had when they were inside the womb.

Benefits:

Kangaroo mother care (KMC) is good for mother and baby:

KMC helps to regulate the baby’s body temperature, increases quiet sleep times, increases weight gain, increases breast feeding, and provides more opportunities for talking and listening to mother’s voice, eye contact and talking to the mother.

KMC helps the mother to bond with her baby and it is good for the development of communication interaction, listening and talking to the baby.

How do I talk to my preterm baby?

Babies will show you when they are ready to “talk” to you.

At first, preterm babies younger than seven months (32 weeks) are in the inturned

state. This means the baby will sleep most of the time and could be stressed easily, especially if the baby is still unstable. The baby’s eyes will mostly be closed. Deep sleep helps the baby grow in this time. Your baby knows your voice and will respond when they are ready.

(Refer to page 10 in the handout. Assist the parents to determine the state of their baby to determine the type of stimulation).

What should I do?

Handling should be done slowly.

If your babies are unstable, ask to hold them close to your body, but avoid moving or rocking the baby.

Provide one type of stimulation: either touching your baby or talking to your baby.

Avoid too much sound and talking: you can hold your baby and sing or talk softly to your baby, but stop when you see stress signals.

Do not give your baby too much to look at, at once: you do not need to make eye contact at this stage because your baby may not be ready yet. Avoid using toys or bright objects.

Give gentle, firm touch when your baby is ready and stop when your baby becomes stressed.

Hold your finger for your baby to hold.

(Demonstrate the above-mentioned to the parents using a doll)

The coming-out state is when your baby is between seven and eight months (32 and

35 weeks) and is starting to interact with you. Your baby is starting to seek social interaction and will want to “listen” to you and will be able to respond.

(Refer to page 11 in the handout. Assist the parents to determine the state of their baby in order to determine the type of stimulation).

What should I do?

Babies open their eyes more frequently, but cannot necessarily make eye contact with you. If your babies are awake and quiet, sit close to the incubator so that they can focus on your face.

Hold out your finger for your baby to hold.

Start with KMC.

You may provide stimulation using mostly your voice by singing or talking softly while your baby is placed in the KMC position or through the open porthole of the incubator.

In the reciprocal state (usually from eight months or 36 weeks), babies will be able to actively “talk” to you. Babies will open their eyes and will stay quiet and alert for longer periods of time.

(Refer to page 12 in the handout. Assist the parents to determine the state of their baby to determine the type of stimulation).

What should I do?

Position babies so that they are able to focus on your face and make eye contact.

Give enough time for your baby to focus on your face and to respond.

Watch your baby’s face and imitate facial expressions such as sticking out your tongue or opening your mouth. You may notice that the baby will look at you for longer periods.

Talk softly to your baby while maintaining eye contact. You can sing any song or talk to your baby about anything. They already know your voice and will find it soothing to listen to you!

Talk to your babies when you are changing their nappies or when you bathe them.

Describe what you are doing. This is good training for babies for when they are older and understand what you are saying.

(Demonstrate the above-mentioned to the parents possibly using a doll. Refer to page 13 in the handout to provide the parents with examples of communication stimulation).

Talk to your baby while you are feeding, unless the baby stops sucking. Rather stop talking if it is distracting your baby from feeding and try again later when your baby is a little older.

Change your talking if you see your baby showing any stress. Place your babies in the KMC position until they are ready for face-to-face interaction again.

Feeding my preterm baby

Feeding and communication: your preterm babies will show signs of stress if they are not yet ready to feed orally. It is important to watch your baby’s reactions.

Feeding is an excellent opportunity for communication interaction (talking to your baby) if your baby is stable and mature enough. During feeding the baby is positioned face to face with the mother, which encourages eye contact. When your baby is ready, feeding on the breast will be recommended to you. Breastfeeding is beneficial for bonding between the baby and mother, which will improve the baby’s social interaction, listening skills and speech.

Sucking reflex: the baby is usually born with a sucking reflex, but preterm babies may not yet be able to coordinate the sucking, swallowing and breathing. Therefore the baby may be placed on tube feeding through the nose or the mouth. You will feed your baby by providing the milk through the tube and therefore your baby will not yet need to suck to get milk. If the baby’s sucking reflex is not stimulated, it may be lost and will result in feeding problems. Non-nutritive sucking (sucking without taking milk into the mouth) teaches the sucking reflex and helps the baby to coordinate the sucking, swallowing and breathing to be able to drink from the breast or the cup.

(Refer to page 14 in the handout for ideas on feeding)

What should I do?

If your babies are stable, you may put them to your breast after you have expressed the breast milk. This is a good way of providing non-nutritive sucking while giving them the milk through the tube.

Allow your baby to suck on your clean finger.

KMC with non-nutritive sucking on mother’s finger will improve the baby’s oral

(mouth) experiences so that feeding will be a positive experience.

Put a drop of breast milk on a cotton swab and place it in the incubator for the baby to smell.

Put a drop of breast milk on your finger when baby sucks on your finger.

Oral feeding: oral feedings should only be started when the baby is stable and mature enough. The nurses will assist you in this process. If there are concerns regarding your baby’s feeding, ask to see a speech-language therapist.

What should I do?

Remember to change the environment: take away bright light and loud noise to help your baby stay calm.

Sit comfortably.

Position your baby in a stable position on your lap.

Allow your baby to set the pace and allow time to rest and breathe.

Do not try to feed your baby when the baby is fussy, crying or in deep sleep.

Avoid talking as this could distract your baby. If your babies are stable and quietly sucking, you may talk to them, but stop if you are distracting them.

6. Conclusion and reflection

Why is it important that my preterm baby is followed up regularly?

(Refer to page 15 in the handout for ideas on follow-up)

Preterm babies are at risk for learning and growing problems. A preterm baby needs to be monitored by a doctor and a team of therapists to identify and treat problems early. We must make sure that your baby is learning to listen and learning to talk well in order for your baby to do well in school one day. An assessment of your baby’s development should be conducted at four, eight and twelve months corrected age to make sure your baby reaches his/her milestones (starts walking and talking at the right time). If a learning problem is identified, it can be treated early in your baby’s life so that they will be ready for school eventually. It will also be wise to have your babies’ eyes and ears tested after they are discharged from the hospital.

Remember to subtract the weeks that your babies were born early from their age to

‘correct’ for prematurity e.g. if your babies were born at seven months pregnancy

(eight weeks too soon) and they are three months old, their corrected age is actually:

3 months (12 weeks) minus 8 weeks (prematurity)

= 4 weeks (1 month) old corrected age

What should I do when I am concerned about my preterm baby?

If you are concerned about your baby in any way, it is important to visit your nearest clinic or hospital immediately to see any of the team members who works with babies and young children such as the speech-language therapist and audiologist.

Time for reflection and questions

The professional should enquire whether any of the parents have any questions about their babies.

Ask the parents which aspects of the discussion they found interesting, in order to encourage personal reflection.

Ask the parents whether they know that their babies can hear and see and if they have started talking or singing to their babies.

Ask whether they have tried KMC and how they experience it. Provide all parents with contact details of the department.

7. Glossary

Auditory system: The fetus can respond to sound as early as 16 weeks gestation, which is before the hearing system is fully developed. The hearing system is fully developed by 23 weeks gestation (Lubbe, 2008:14).

Coming-out state: The developmental state of an infant between the ages of 32 and

35 weeks gestation, who requires constant medical care but is not critically ill anymore (Lubbe, 2008:64).

Containment: Body containment increases the infant’s feelings of security and selfcontrol and decreases stress. Infants who are contained tend to be calmer and gain weight more rapidly (Lubbe, 2008:92).

Corrected age: Chronological age - (40 minus gestational age at birth). The corrected age is used to calculate catch-up growth. An infant’s age should be corrected for prematurity until at least two years of age (Lubbe, 2008:274; Rossetti,

2001:112).

Developmental care: Within the developmental care approach, infants are viewed to be active participants in their own care and are focused on interventions that protect the premature or sick infant’s immature central nervous system (Als,

1997:57; Klaus & Fanaroff, 2001:224). Developmentally supportive care leads to increased weight gain, shorter stays in hospital, shorter time on ventilators (Bozzette

& Kenner, 2004:79), improved medical as well as behavioural outcomes, improved brain and motor development (Als, 1997:62).

Developmental delay: Defined in two ways: (1) a significant lag in attaining developmental milestones or skills attributable to known or unknown factors; (2) lifelong deficits or anomalies that require ongoing provision of training to achieve adaptive behaviours and can require ongoing use of equipment or supportive assistance in personal care. It is essential that the professional understand the manner in which the term developmental delay is being used. Families and some professionals use the term to include a functional delay in acquisition of developmental milestones, whereas others use it to define lifelong disabilities

(Billeaud & Broussard, 2003:288).

Flexion position: The womb provides the fetus with boundaries and supported the unborn infant to remain in a curled-up fetal position. The flexed fetal position has many benefits: it decreases the stress caused by extended limbs, encourages selfregulating, normal growth, posture, development and movement control, leads to physiological stability and promotes sleep and rest (Lubbe, 2008:89).

Full-term: The description of the level of maturation of an infant born between 37 and 41 weeks’ gestation (Billeaud & Broussard, 2003:289).

Gestation/gestational age: The age of an infant at delivery as calculated from the day of conception to the date of delivery (Billeaud & Broussard, 2003:289).

Infant: For the purpose of this programme, any infant hospitalised in the NICU, neonatal high care or KMC ward is referred to as infant or baby.

Inturned state: The developmental state of an infant before 32 weeks gestation.

The infant will require constant medical support such as breathing with the help of a ventilator and will be physiologically unstable (heart rate, breathing, blood pressure)

(Lubbe, 2008:60).

Kangaroo mother care (KMC): KMC is a form of tactile-kinesthetic stimulation. The infant is dressed in a nappy and cap and placed skin-to-skin on the mother’s chest.

KMC has numerous benefits including improved saturation, increased weight gain and improved mother-child interaction (Lubbe, 2008:102; Rossetti, 2001:274).

Low birth weight: Defined as birth weight between 1500 – 2500 grams, while very low birth weight refers to < 1500 grams and extreme low birth weight is < 1000 grams

(Billeaud & Broussard, 2003:291; Lubbe, 2008:26).

Neonatal intensive care unit (NICU): A specialised hospital nursery facility designed for infants with critical care needs (Billeaud & Broussard, 2003:292).

Neonate: Newborn infant through the age 28 days (Billeaud & Broussard, 2003:292).

Non-nutritive sucking: Repetitive actions of sucking and swallowing, followed by breathing and is not used for feeding such as sucking on a thumb or finger (Lubbe,

2008:136).

Nutritive sucking: Nutritive sucking or feeding is the step that follows non-nutritive sucking meaning that the infant is ready to feed orally by sucking (Lubbe, 2008:142).

Oxygen saturation: The level of oxygen in the infant’s blood. Normal blood saturation for premature infants are approximately 88 – 92% when the infant receives oxygen and above 96% when he/she is breathing on his/her own (Lubbe, 2008:38).

Premature/preterm: For the purpose of this study, the terms premature and preterm are used interchangeably. Prematurity is the delivery of an infant before the thirtyseventh week of gestation. Extreme prematurity, before 28 weeks gestation, places the infant at risk for developmental problems, including language disorders (Billeaud

& Broussard, 2003:293; Lubbe, 2008:26).

Proprioception system: The infant perceives motion or positioning of the limbs of the body through muscle and joint sensations such as stretching or contracting. It develops in conjunction with the vestibular system (Lubbe, 2008:8).

Reciprocity state: The final stage of interaction from 36 weeks and onwards when the infant is ready to actively interact with his/her environment. The infant will respond in predictable ways and recover from agitation using self-regulating behaviour (Lubbe, 2008:64).

Retinopathy of prematurity (ROP): A condition caused by excessive or prolonged use of supplementary oxygen in premature babies during the perinatal period, which

adversely affects the infant’s retina; associated with reduced visual acuity (Billeaud

& Broussard, 2003:294).

Self-regulatory behaviour: Signs that an infant uses to self-calm such as putting hands to mouth (Lubbe, 2008:77).

Stress signal: Signals an infant uses to communicate that he/she is not ready for handling, activity or interaction such as sneezing, hiccupping or making fists (Lubbe,

2008:79).

Swaddling: Wrapping the infant tightly in a blanket with arms and legs bent up and hands close to his/her mouth (Lubbe, 2008:132).

Tactile (touch) system: The infant’s skin is fragile and may be overactive in premature infants as it serves to protect against injury (Lubbe, 2008:98).

Vestibular system: Through this system the infant receives information regarding its bodily positioning in space, which is the ability to balance itself through gravitation and is therefore sensitive to movement and change in position (Lubbe, 2008:8).

Visual system: The infant’s vision is the last system to mature. The infant responds to light from 24 to 26 weeks gestation. By 32 weeks the circuits for simple eye movements are functioning (Lubbe, 2008:16).

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Photos in handout from Dreamstime or Getty Images unless otherwise specified

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[Online]. Available: www.how-to-travel-the-world.com/images/cellphone.jpg, Viewed 03/08/2009.

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[Online]. Available: www.made-in-china.com/image/2f0j00svBQgwdzCtpIM/Boombox-DVD-VCD-MP3-CD-Player-

BM-893DVD-.jpg, Viewed 03/08/2009.

Photo of television in handout from:

[Online]. Available: www.dicts.info/img/ud/television.png, Viewed 03/08/2009.

Photo of man talking on cell phone from:

[Online]. Available: www.careers.sky.com/images/gallery/loudtalking_medium.jpg, Viewed 03/08/2009.

Photo of father swinging baby from:

[Online]. Available: www.floridaestateplanninglawyerblog.com/Father-swinging-baby.jpg, Viewed 03/08/2009.

Photo of mother bouncing baby on ball from:

[Online]. Available: www.fitnotic.com/pics/p4/5.jpg, Viewed 03/08/2009.

Neonatal Communication

Intervention Programme for

Parents

Presented by

Speech-language therapy and Audiology

Compiled by: E. Strasheim

M.Comm.Path.

University of Pretoria (2009)

1. Introduction

What is a premature baby?

Why does my premature baby need special care?

How can prematurity affect my baby’s talking and listening?

What is developmental care?

Why is developmental care important?

2. Understanding my baby’s behaviour

Can my premature baby hear me and see me?

2. Understanding my baby’s behaviour

What are my premature baby’s stress signals?

- Changes: heart rate, blood pressure, breathing,

oxygen saturation, skin colour.

- hiccup, gag/vomit, sigh, yawn, sneeze, strain,

tongue thrust, frown, sit on air, finger/toe splays, arching back, grimace, frantic movement, fussy/crying, low alertness.

2. Understanding my baby’s behaviour

When does my premature baby show stress signals?

Stress from:

↑ noise, ↑ light, ↑ movement, ↑ touch

What are self-regulatory behaviours?

9

hand to mouth

9

hand to face

9

sucking

9

hand holding

9

finger grasping

9

flexion position

3. What should I do to help my baby develop?

What can I do when my baby is stressed or cries?

3

↓ noise, ↓ light, ↓ touch,

↓ movement

3

Position

3

Swaddle

3

Containment hold

3

KMC

3. What should I do to help my baby develop? (cont)

What is kangaroo mother care?

3

Copies feeling baby had in womb

3

Benefits

3

Can be used when baby cries and shows stress

3. What should I do to help my baby develop? (cont)

How do I talk to my baby?

Inturned state

3 holding, 3 one stimulation (talk or touch),

3 finger grasp, 3 firm touch 3 slow handling

Coming-out state

3 finger grasp, 3 KMC, 3 eye contact through incubator, 3 sing, 3 talk

Reciprocal state

3

KMC 3 talk, 3 describe, 3 sing,

3 eye contact, 3 facial expression

3. What should I do to help my baby develop? (cont)

Feeding my baby

3

NNS (clean finger, breast) while tube-fed

3

KMC frequently

3

Transition to oral feeds

with assistance: calm environment, stable position, baby awake, talk to baby.

4. Conclusion

Why is it important that my baby is followed-up regularly?

9

Risk for developmental delay, learning problem

9

Follow-up every 4 months

What should I do when I am concerned about my baby?

9

Clinic, hospital

9

Speech-language therapist & audiologist

Questions

My baby’s talking book

My Baby’s name:

Date of birth:

My name:

Compiled by Esedra Strasheim (M.Comm.Path – University of Pretoria, 2009)

1

Introduction

What is a preterm baby?

A preterm baby is a baby who was born too soon (before 8 months of pregnancy or more than one month before the due date).

Why does my preterm baby need special care?

A baby who was born too soon needs special help to grow and develop.

Preterm babies become stressed or over-stimulated easily by too much noise, or light or too much movement, handling or touching, which can affect their development and learning.

How can prematurity affect communication development?

A preterm baby is hospitalised and cannot have normal interaction with his mother and father, which can affect his learning.

Baby may have problems with hearing, seeing and touch, which affects learning to listen and talk.

What is developmental care?

Mother and father as well as the nurses

changes the environment of the

hospital room so that the baby will not

become stressed.

Helps mother, father and nurses to

understand what the baby is trying to

say.

Why is developmental care important?

Developmental care attempts to copy the conditions in the womb to reduce stress to babies and help them grow and learn.

2

Understanding my baby’s behaviour

Can my preterm baby hear me and see me?

X /

3

Hear

See

Feel (light touch, movement, deep touch)

3

What are my preterm baby’s stress signals?

If you see babies showing any of these signals, it means that they are stressed or over-stimulated and needs a time-out.

Changes in heart rate, breathing, colour

X

/

3

Hiccup

Gag/vomit

Sigh

Arching back

Sneeze

Tongue thrust

Frown

Sit on air

Yawn

Strain

Finger/toe splays

4

Showing stop

Frantic movement

Fussy/crying

Low alertness

Fatigue

5

When does my baby show stress signals?

X / 3

Loud noise or talking

Soft talking

Bright light

Dim light

Movement

Touch or handling

6

What are self-regulatory behaviours?

Babies do these movements to help them not to stress.

Hand holding/hand to mouth movement

Hand to face movement

Sucking

Grasping your finger

Flexion position

7

What should I do to help my baby learn?

What can I do when my baby shows stress signals and cries?

noise,

↓ light,

↓ touch,

↓ movement

Position

Swaddle

Containment

KMC

8

What is kangaroo mother care (KMC)?

KMC copies the feeling the baby had in the womb.

KMC can be used when baby shows stress or cries and is good for bonding and feeding.

9

How do I communicate with my preterm baby?

Baby needs special interaction at every stage of learning:

Inturned state (before 7 months)

3

Hold baby in your arms if unstable.

3

Give one stimulation at a time (talk or touch).

3

Hold your finger for baby to grasp.

3

Give firm gentle touch.

3

Handle and move baby slowly.

3

Give babies ‘time-out’ baby when they

show stress.

10

Coming-out state (between 7 and 8 months)

3

Hold your finger for baby to grasp.

3

Do KMC frequently.

3

Make eye contact with baby

through incubator.

3

Sing to baby.

3

Talk to baby.

3

Give babies ‘time-out’ when

they show stress.

11

Reciprocal state (from 8 months)

3

Do KMC frequently.

3

Talk to baby.

3

Describe what you are doing.

3

Sing to baby.

3

Position baby face to face.

3

Make eye contact with baby.

3

Imitate baby’s facial expressions

e.g. stick out tongue.

12

Things I can say to babies when they are ready

You are a good baby.

You are growing so fast.

Mommy loves you.

You have a beautiful face.

You have cute toes.

You will be a big boy/girl.

You opened your eyes.

You are sucking your thumb.

You look happy today.

You look sleepy now.

You have two ears.

You are sucking your thumb.

I like the way you smile.

13

Feeding my preterm baby

Your baby may need tube feeding at first and will then move to cup or breast feeding.

3

Non nutritive sucking is important (use a clean finger for baby to suck on, or give expressed breast to suckle on) while baby is tube-fed to stimulate the sucking reflex.

3

Do KMC frequently to promote positive oral (mouth) experiences.

3

Move to oral feeds with help from the nurses or the speech-language therapist (the environment must be calm, baby in good position, baby awake, talk to baby while feeding to stimulate talking and interaction).

14

Conclusion

Why is it important that my preterm baby is followed-up regularly?

All preterm babies have a risk for problems with learning, hearing, talking or seeing.

Follow-up every 4 months at hospital/clinic to make sure that baby is learning.

What should I do when I am concerned about my preterm baby?

Visit your local clinic or hospital

Ask to see the Speech-language therapist or

Audiologist

15

Incwadi yokukhuluma yomntanami

Igama lomntanami:

Usuku lokuzalwa:

Igama lami:

Ihlanganiswe i-Esedra Strasheim

(M.Comm.Path – University of Pretoria, 2009)

1

Isethulo

Onjani umntwana ozalwe singakafiki isikhathi?

Umntwana ozalwe singakafiki isikhathi ngumntwana osheshe wazalwa (umama engakabi nezinyanga ezingu-8 ekhulelwe noma ozalwe kusasele inyanga nangaphezulu kufike isikhathi sakhe).

Kungani umntanami ozalwe singakafiki isikhathi edinga ukunakekelwa okukhethekile?

Umntwana osheshe wazalwa udinga usizo olukhethekile ukuze akhule futhi athuthuke.

Abantwana abazalwe singakafiki isikhathi bayacindezeleka noma bashukumiseke ngokweqile kalula uma kunomsindo omkhulu, ukukhanya noma ukunyakaza kakhulu, ukuphathwa noma ukuthintwa, okungase kuphazamise ukukhula kwabo nokufunda.

Ukuzalwa singakafiki isikhathi kungakuthinta kanjani ukukhula okuphathelene nokuxhumana?

Umntwana ozalwe singakafiki isikhathi ulaliswa esibhedlela futhi ngeke axhumane ngendlela evamile nonina noyise, okungase kuthikameze ukufunda kwakhe.

Umntwana angase abe nenkinga yokuzwa, ukubona nokuthinta, okuthikameza ukufunda ukulalela nokukhuluma.

Kuyini ukunakekelwa kokukhuliswa

(developmental care)?

Umama nobaba kanye namanesi bashintsha indawo yegumbi lasesibhedlela ukuze umntwana angacindezeleki.

Kusiza umama, ubaba kanye namanesi ukuba baqonde lokho umntwana azama ukukusho.

Kungani kubalulekile ukunakekelwa kokukhuliswa?Ukunakekelwa kokukhuliswa kuzama ukukopisha izimo zasesibelethweni ukuze kuncishiswe ukucindezeleka kubantwana futhi basizwe bakhule futhi bafunde.

2

Ukuqonda ukuziphatha komntanami

Umntanami ozalwe singakafiki isikhathi angangizwa yini futhi angibone?

x 3

Ukuzwa ezindlebeni

Ukubona

Ukuzwa okwenzekayo

(ukuthintwa kancane, umnyakazo, ukuthintwa okujulile)

3

Yiziphi izimpawu zokucindezeleka zomntanami ozalwa singakafiki isikhathi?

Uma ubona abantwana bekhombisa noma yiziphi kulezi zimpawu, kusho ukuthi bacindezelekile noma bashukumiseke ngokweqile futhi badinga isikhathi sokuphumula.

Ukushintsha kokushaya kwenhliziyo, kokuphefumula, kombala x 3

Ingwici

Ukuhilwa/ukuphalaza

Ukububula

Umhlane obuhlungu

Ukunyukubala

Ukuthimula

Ukukhipha ulimi

Ukubipha

Ukuhlala emoyeni

Ukuzamula

Ukuzelula

Ukuqhansa iminwe

/nezinzwane

4

Ukubonisa

uphawu oluthi yima

Ukujilajileka

Ukutetema/

ukukhala

Ukungaphaphami kahle

Ukukhathala

5

Umntanami uzibonisa nini izimpawu zokucindezeleka?

Umsindo omkhulu noma ukukhuluma

Ukukhulumela phansi

Isibani esigqamile

Isibani esilufifi

Ukunyakaziswa

Ukuthintwa noma ukuphathwa

x

3

6

Yini ayenzayo yokuzisiza?

Abantwana benza lokhu ukuze bazisize bangacindezeleki.

Ukubamba isandla/ukuf aka isandla emlonyeni

Ukubeka isandla ebusweni

Ukuncela

Ukubamba umunwe wakho

Ukugoba

7

Yini okufanele ngiyenze ukuze ngisize umntanami afunde?

Yini engingayenza lapho umntanami ekhombisa izimpawu zokucindezeleka futhi ekhala?

umsindo,

ukukhanya,

ukuthinta,

↓ ukumnyakazisa

Simo sokulala

Ukumsonga

Indlela yokumbamba

I-KMC

8

Okunjani ukunakekela kukamama okunjengokwe-kangaroo (KMC)?

3

3

3

I-KMC ilingisa indlela ayezizwa ngayo umntwana lapho esesibelethweni.

I-KMC ingasetshenziswa lapho umntwana ebonisa ukucindezeleka noma ekhala.

I-KMC ikahle ukuze umama nomntwana bakhe isibopho sothando futhi amncelise.

9

Ngixhumana kanjani nomntanami ozalwe singakafiki isikhathi?

Umntwana udinga ukuxhumana okukhethekile esinyathelweni ngasinye sokufunda:

Isimo sokubuyela phakathi (inturned state) (ngaphambi kwezinyanga ezingu-7)

3

3

3

3

3

3

Mgone umntwana uma engahlaliseki.

Yenza okukodwa okuzomshukumisa ngesikhathi

(khuluma noma uthinte).

Khipha umunwe wakho ukuze umntanakho awubambe.

Mthinte kahle ngodwa uqinise.

Phatha umntwana futhi umsuse kancane.

Nikeza abantwana ‘isikhathi sokuphumula’ lapho bekhombisa ukucindezeleka.

10

Isimo sokuphuma (coming-out state) (phakathi kwezinyanga ezingu-7 nezingu-8)

3

Khipha umunwe wakho ukuze umntwana awubambe.

3

Yenza i-KMC njalo.

3

Mbuke emehlweni umntanakho esemshinini.

3

Mculele umntwana.

3

Khuluma nomntwana.

3

Nikeza abantwana ‘isikhathi sokuphumula’ lapho bekhombisa ukucindezeleka.

11

Isimo sokusabela (reciprocal state) (kusuka ezinyangeni ezingu-8)

3

Yenza i-KMC njalo.

3

Khuluma nomntwana.

3

Mchazele ukuthi wenzani.

3

Mculele umntwana.

3

Bhekisa ubuso bakhe kobakho.

3

Mbheke emehlweni umntwana.

3

Lingisa lokho akwenzayo ebusweni isib. khipha ulimi.

12

Izinto engingazisho kubantwana lapho sebekulungele

Ungumntwana omuhle.

Ukhula masisha.

Umama uyakuthanda.

Unobuso obuhle.

Unezinzwane ezinhle.

Uzoba umfana/intombazane ekhulile.

Uvule amehlo.

Uncela isithupha sakho.

Ubukeka ujabule namhlanje.

Ubukeka wozela manje.

Unezindlebe ezimbili.

Uncela isithupha sakho.

Ngiyayithanda indlela omomotheka ngayo.

13

Ukuncelisa umntanami ozalwa singakafiki isikhathi

Umntanakho angase adinge ukunceliswa ngeshubhu ekuqaleni abe esedlulela ekunceleni ngenkomishi noma ekunceleni ibele.

3

Ukuncela into engadliwa kubalulekile (sebenzisa umunwe ohlanzekile ukuze umntwana awuncele, noma umkhiphele ibele ulibambe ukuze ancele) ngesikhathi umntwana esancela ngeshubhu ukuze ushukumise izinzwa zokuncela.

3

Yenza i-KMC kaningi ukuze uthuthukise ukukhuluma naye okuhle.

3

Dlulela ekumfunzeni ngosizo lwamanesi noma umelaphi obhekelela ukukhuluma nolimi (indawo kumelwe ibe ezolile, umntwana abe sesimweni esikahle, umntwana abe ophapheme, khuluma nomntwana ngesikhathi umncelisa ukuze ushukumise ukukhuluma nokuxhumana).

14

Isiphetho

Kungani kubalulekile ukuthi umntanami ozalwe singakafiki isikhathi alandelelwe njalo?

Bonke abantwana abazalwe singakafiki isikhathi basengozini yezinkinga zokufunda, ukuzwa, ukukhuluma noma ukubona.

Landelela njalo emva kwezinyanga ezine uye esibhedlela

/emtholampilo ukuze uqiniseke ukuthi umntwana uyafunda.

Yini okufanele ngiyenze uma ngikhathazeka ngomntanami ozalwe singakafiki isikhathi?

3

Vakashela emtholampilo noma esibhedlela sangakini.

3

Cela ukubona uMelaphi wokukhuluma nolimi noma i-

Audiologist.

15

Appendix H

APPENDIX H – Cover letter and pilot study questionnaire (Phase 2)

Dear Speech-language therapist

You are requested to participate in the pilot study of a neonatal communication intervention tool for parents/caregivers as part of a Master’s Degree in Communication Pathology at the

University of Pretoria.

You are requested to present the attached programme during your treatment in the NICU,

Neonatal high care ward or KMC ward at your hospital with a small group of parents/caregivers whose infants are in the neonatal nursery. Please provide feedback and comments to me thereafter by completing the attached questionnaire and sending it back via e-mail or facsimile.

Your identity, the identity of your institution as well as your answers will be handled confidentially. If at any stage you feel that you do not longer want to participate, you are free to withdraw. If you have any questions regarding this study, you are welcome to contact the researcher at 082 461 72 48.

Attached is the following:

- 1 x The Neonatal Communication Intervention programme for parents

(complete programme for your use).

- 1 x The Neonatal Communication Intervention programme for parents

(PowerPoint presentation on CD).

- 1 x The Neonatal Communication Intervention programme for parents

(printed on transparencies).

- 4 x handouts (English and IsiZulu) hardcopy as well as on the CD.

- 3 x questionnaires.

Instructions:

- You are requested to present the programme during your treatment in the NICU, Neonatal high care ward or KMC ward at your hospital with a small group (approximately four) of parents/caregivers whose infants are in the neonatal nursery.

- You may select the venue for the programme to be presented.

- You may use the PowerPoint presentation on the CD or the transparencies if you are not equipped with a lap-top computer.

- You are also requested to use the handouts regardless of the parents’ literacy levels. Please make more copies of either handout if necessary.

- Please provide feedback and comments to me thereafter by completing the questionnaire and sending it back via e-mail or facsimile.

Thank you for your willingness to participate in this project and the time you spent despite a busy schedule.

________________________________

Esedra Strasheim

082 461 72 48

Email: [email protected]

Facsimile: 086 613 0625

Appendix H

Pilot study questionnaire

Development of a neonatal communication intervention tool

Esedra Strasheim

Department of Communication Pathology

University of Pretoria

Please complete the following questionnaire regarding the tool/materials that was provided to you for use in the NICU, Neonatal High Care (NHCU) and KMC ward of your hospital.

Please answer each question. Tick the appropriate option or answer the question where applicable. Please fax or email this questionnaire back to the researcher at 086 6130 625 (f) or [email protected]

Participant number:

Highest qualification:

Years of working experience:

Section A: Format of the tool

1. Please rate the format and presentation of the tool with an x in the appropriate block:

PowerPoint presentation

Handouts

Transparencies

Complete programme for your use

2. Do you feel that the tool’s format was useful in assisting you in service provision in the NICU/NHCU/KMC?

Definitely Probably Unsure Probably not Definitely not

3. What would you like to change regarding the format of the tool? Please provide any comments or suggestions:

Section B: Content of the tool

4. Please rate the content included in the tool by selecting one option:

Appendix H

5. Do you feel that the tool’s content was useful in assisting you in service provision in the NICU/NHCU/KMC?

Definitely Probably Unsure Probably not Definitely not

6. Please rate the language and terminology used in the tool:

Good Adequate

Please provide any comments or suggestions:

7. Indicate whether you feel the following themes should be included in the tool:

Theme

Prematurity and low birth weight

Definitely Probably Unsure Probably not

Infant’s capabilities (tactile system, auditory system, visual system)

Developmental care (general awareness)

Stress behaviours

Noise in the nursery

Light in the nursery

Handling in the nursery

Adaptations in the nursery to reduce stimuli

(noise & light reduction, clustered care)

Self-regulating behaviour

Kangaroo mother care

Positioning

Calming techniques (e.g. swaddling, nesting)

Communication stimulation

Feeding

Follow-up services (general awareness)

8. What would you like to change regarding the content of the tool? Please provide any comments or suggestions:

Section C: Possible future enhancements to the tool

9. What enhancements you would prefer before using the tool again? Please provide any comments or suggestions:

Definitely not

Thank you for using the tool and completing this questionnaire

Was this manual useful for you? yes no
Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

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