Original Article Egyptian Journal of Health Care, 2018 EJHC Vol.9 No.

Assessment of Nurses' Knowledge and Practice Regarding to Kangaroo

Care at Neonatal Intensive Care Unit (NICU)

Wafaa El-Sayed, Zeinab Fathy, Nesreen Abd El Wahab

Pediatric Nursing, Faculty of Nursing, Ain Shams University, Cairo, Egypt

Abstract

A descriptive study was carried out, aiming to assess knowledge and practices of neonatal
nurses regarding kangaroo care. Setting at the neonatal intensive care units of children‟s hospital,
affiliated to Ain Shams University hospitals. The total sample were 50 nurses who worked in
neonatal intensive care units. Tools of the study involved; interview questionnaire sheet, to
assess characteristics of the nurses and their knowledge about kangaroo mother care, and an
observation checklist adopted from World Health Organization, (2013) to assess nurses‟
practices regarding maternal kangaroo care. The main results showed that more than half of the
nurses had satisfactory total knowledge levels regarding prematurity and kangaroo care, and
slightly less than half of them had satisfactory total practice levels of regarding kangaroo care.
There were statistically significant differences between nurse‟s knowledge of kangaroo and their
age, educational level, years of experience in NICU and previous training courses in kangaroo
care. The study concluded that nurses‟ knowledge and practice regarding premature baby and
kangaroo care were satisfactory by nearly half of the studied sample. The study recommended
that kangaroo care technique should be a part of the routine care for all premature and lowbirth
weight newborn infants admitted to NICU.

Key words: prematurity, kangaroo care, Nurses knowledge, Nurses Practice.

Introduction
In the past, premature birth was the by specially trained physicians and nurses in
major cause of infant mortality. Today, the a neonatal intensive care unit (NICU)
quality of neonatal care has greatly improved (Blencowe et al., 2012).
and high percent of infants born as early as
28 weeks now survive. However, preterm In the 1970s, Columbian Pediatrician
birth is still the top cause of infant deaths Edgar Rey was looking for a way to keep
worldwide, according to a 2010 study which premature infants warm in an area that was
is published in the British medical journal too poor to provide incubators for its
lancet. Birth is considered premature or preemies. He had mothers of preemies hold
preterm when it occurs before 37 weeks of their infants continuously, wearing only a
gestation. Normally full term gestation is 37 diaper, upright between their breasts. Not
to 42 weeks. Premature infant weight much only did the infants stay warm, but they
less than infants born full term. They also seemed to leave the hospital earlier and with
have serious health problems that require a better breast feeding rates (Flacking et al.,
long stay in the hospital. They are cared for 2011).

EJHC 291
 Assessment of Nurses' Knowledge and Practice Regarding to Kangroo Care at Neonatal
Intensive Care Unit (NICU)
Kangaroo care has become much regarding maternal kangaroo care (MKC)
more than a way to keep infants warm in that consequently can help in better quality of
undeveloped nations, it's common in modern care and overcoming the possible barriers
NICUs and studies have proven that it has a hindering MKC for neonates at neonatal
number of benefits for mothers and for intensive care unit (NICU).
infants. Kangaroo care is a way of holding
infants skin to skin with a mother. In Aims of the study:
kangaroo care, an infant is undressed down to
the diaper and placed on a mother's bare The aim of the study is to assess
chest. A blanket is placed over the infant for knowledge and practice of neonatal nurses
warmth (Cong et al., 2011). regarding kangaroo care through the
followings:
Kangaroo care has been shown to
have several benefits for premature infants 1. Assessing nurses' level of knowledge
and their mothers. It helps infants breath and regarding kangaroo care for premature
sleep better, gain weight more a quickly and baby.
have more stable temperature. Mothers who
practice kangaroo care have better milk 2. Assessing nurses' level of practice
supplies and less depression and mothers regarding kangaroo care for premature
who practiced continuous kangaroo mother baby.
care (KMC) (24h/day) have reported that
they liked having this close contact with their
Research questions:
infant and that they felt safe with this care
(Conde-Agudelo et al., 2011).
1- What is the level of nurses'
knowledge and practices regarding to
It has been recommended that staff
kangaroo mother care?
initiate continuous kangaroo mother care
(KMC), as soon as possible after the infant is
2- Is there a relation between
born and after initial resuscitation and
characteristics of the nurses at neonatal
stabilization (Nyqvist et al., 2010).
intensive care unit and their knowledge and
practice regarding to kangaroo care?
NICU nurses‟ attitudes in skin to skin
contact (SSC) practice are ambivalent. The
Subject and Methods:
nurses consider the sensory, wellness, and
mutuality experiences to be primary and vital
Research Design:
and enact SSC as much as possible. But “as
much as possible” is a broad and varied
concept, and their attitudes are ambivalent in Descriptive design.
terms of not always facilitating what they
consider to be the optimal caring conditions. Setting:
The source of NICU nurse's ambivalent
attitudes in SSC practice is a complex This study was conducted in the unit
interplay of beliefs, norms, and evidence, of neonatal intensive care unit of Children's
which have a multidisciplinary basis (Cong Hospital, affiliated to Ain Shams University.
et al., 2011).
Subject:
Significance of the Study:
The study sample consisted of a
convenient sample of nurses working in the
It's important to carry out this study previously-mentioned setting. The total
to shed light on nurses‟ knowledge and skills

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 Wafaa El Sayed Ouda, Zeinab Fathy, Nesreen Abd El Wahab

number of nurses was (50; 15 males + 35 The scoring system for the studied
females), regardless their age, gender, marital nurses‟ knowledge was designed as follows:
status, qualifications, level of education, A score was assigned for each question
years of experience or attendance of concerning specific items. According to the
educational courses relevant to KMC. nurses‟ answers, the scores were summed up
and converted into percentages.
Tools for data collection:
The total score was (47) marks. Each
A pre-designed nurse’s correct answer was given (one) mark and the
questionnaire: incomplete correct answer was given (zero).
A knowledge score ≥ 60% was considered
It was designed to assess nurses‟ satisfactory, while < 60% was considered
socio-demographic characteristics and their unsatisfactory.
knowledge regarding premature infants and
kangaroo care, it included the following Tool II: Observational checklist
parts: (Appendix III):

Part 1: It is consisted of (6) questions The observational checklist was

concerned with the socio-demographic adopted from the WHO (2013), to assess
characteristics of the nurses such as age, nurses‟ actual practice regarding kangaroo
qualifications, years of experience and care in premature infants. Each nurse was
attendance of previous training courses observed and evaluated by the researcher
relevant to KMC. using the observational checklist. The time
consumed to observe the studied nurses
Part 2: It is consisted of (6) questions ranged from 20-30 minutes for each one.
related to premature infants to measure
nurses‟ knowledge regarding: the normal  scoring system
weight of infants at birth, in addition to the
definition, causes, complications and for the practice of the studied nurses
methods of prevention of prematurity in regarding KMC was designed as follows: it
infants. contained 8 steps, each step scored (1) if
done correctly and (0) if not done. A total
Parts 3-7: It consisted of (35)
questions related to kangaroo care for score level 60% was regarded as
premature infants, like: previous training unsatisfactory; while a score  60% was
about kangaroo care, in addition to nurses‟ regarded as satisfactory.
knowledge regarding definition, position,
benefits, and obstacles of kangaroo care. Observational checklist:

In addition, it included questions The observational checklist was

concerned with: the nurses‟ application of adopted from the WHO (2013), to assess
kangaroo care, their knowledge about where nurses‟ actual practice regarding kangaroo
and who can apply it, the type of premature care in premature infants.
infants in need to receive kangaroo care, its
benefits for the premature newborn infants Pilot study:
and mothers, the nurses‟ knowledge about
kangaroo care and the nursing role regarding Before performing the actual study, a
kangaroo care. pilot study was carried out, which included
(10%) nurses in the previously-mentioned
setting to test the clarity and applicability of

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 Assessment of Nurses' Knowledge and Practice Regarding to Kangroo Care at Neonatal
Intensive Care Unit (NICU)
the study tools and the time needed to fill clarified the aim and procedures of the study
each one. The nurses involved in the pilot to each study subject before starting the
study were included in the main study actual field work. The researcher assured
sample. maintaining the anonymity and
confidentiality of the subjects‟ data. The
Field work: studied nurses were informed that they were
allowed to choose to participate or not in the
The researcher started by introducing study and they had the right to withdraw
herself to the studied nurses and giving them from the study at any time.
a brief idea about the aim of the study. The
researcher was available two days/week Statistical design:
during morning and afternoon shifts. The
predesigned questionnaire sheet was filled by Data were revised, coded, tabulated
each nurse. The time consumed to answer the and analyzed using number and percentage
questionnaire sheet ranged from 20-30 distribution using SPSS (Statistical Package
minutes for each nurse. Each nurse was for Social Sciences) software. Proper
observed and evaluated by the researcher statistical tests were used to determine
using the observational checklist. The time whether there was a significant statistical
consumed to observe the studied nurses difference or not.
ranged from 20-30 minutes for each one.
Significance of results:
Ethical considerations:
- At P < 0.05, there was a statistically
The research approval was obtained significant difference.
from the ethical research committee at the
Faculty of Nursing, Ain Shams University - At P > 0.05, there was no
before conducting the study. The researcher statistically significant difference.
Result
Table (1): Distribution of the studied nurses according to their socio-demographic
characteristics (n=50).

Items No. %
Age:
< 20 3 6.0
20<25 20 40.0
25<30 13 26.0
30<35 9 18.0
35≤40 5 10.0
Mean±SD 26.57±5.31
Gender:
Male 15 30.0
Female 35 70.0
Educational level:
Master degree 9 18.0
Bachelor degree 11 22.0
Technical nursing diploma 18 36.0
Technical nursing diploma and specialty 12 24.0

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Table (1): shows that, age of 40 % of the studied nurses were ranged from 20< 25 years. In
relation to their gender it was found that 70% of them were females, regarding to their educational
level, it was found that 36% of them had technical nursing diploma while 22% of them had bachelor
degree.

Table (2): Distribution of the studied nurses according to their years of experience in NICU
and previous training in kangaroo care (n=50).

Items No. %
Years of experience in NICU:
<1 9 18.0
1<5 24 48.0
5<10 14 28.0
10<15 2 4.0
15≤20 1 2.0
Mean±SD 6.04±2.88
Previous training in kangaroo care:
Yes 6 12.0
No 44 88.0

Table (2): Concerning years of experience, this table shows that, about half of studied nurses
(48%) reported 1<5 years of experience in neonatal intensive care units, and only 12% of them had
previous training in kangaroo care.

Table (3): Distribution of the studied nurses regarding their total knowledge about premature
infants and kangaroo care (n=50).

Total knowledge No. %

Satisfactory 27 54
Unsatisfactory 23 46

Table (3): showed that 54% of the studied nurses had satisfactory levels of total knowledge
regarding premature infants and kangaroo care.

Table (4): Distribution of the studied nurses regarding their total practice of kangaroo care
(n=50).

Total practice No. %

Satisfactorily done 21 42
Unsatisfactorily done 29 58

Table (4): showed that 42% of the studied nurses had satisfactory levels of practice
regarding kangaroo care for premature infants.

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Intensive Care Unit (NICU)
Table (5): Relation between the characteristics of the studied nurses and their total
knowledge regarding premature infants (n=50).

Total Knowledge Chi-square test

Satisfactory Unsatisfactory
Characteristic data
(N=27) (N=23) X2 P-value
No. % No. %
Years of experience in NICU:
<1 1 3.7 8 34.8
1<5 12 44.4 12 52.2
5<10 12 44.4 2 8.7 13.353 0.009
10<15 1 3.7 1 4.3
15≤20 1 3.7 0 0.0

Table (5): showed the relation between total nurses‟ knowledge and their years of
experience. It is clear that there were statistically significant differences between nurses‟ total
knowledge regarding premature infants and kangaroo care and their years of experience in NICU
where = 13.353 with P-value = 0.009.

Table (6): Relation between studied nurses‟ characteristics and their total practice in
kangaroo care (n=50).

Total practice Chi-square test

Characteristic data Done (N=21) Not done (N=29)
X2 P-value
No. % No. %
Qualifications:
Master degree. 9 42.9 0 0.0
Bachelor degree. 6 28.6 5 17.2
Technical nursing diploma. 4 19.0 14 48.3 19.191 <0.001
Technical nursing diploma and
2 9.5 10 34.5
specialty.
Years of experience in NICU:
<1 0 0.0 9 31.0
1<5 5 23.8 19 65.5
5<10 13 61.9 1 3.4 29.399 <0.001
10<15 2 9.5 0 0.0
15≤20 1 4.8 0 0.0
Previous training in kangaroo care:
Yes. 6 28.6 0 0.0
6.904 0.009
No. 15 71.4 29 100.0

Table (6): showed the relation between nurses‟ characteristics and their total practice. It is
clear that there were statistically significant differences between nurses‟ total practice regarding
kangaroo care and their qualification, years of experience in NICU, and previous trainings in
kangaroo care where = (19.191, 29.399 and 6.904, with P-value = < 0.001, < 0.001, 0.009).

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 Wafaa El Sayed Ouda, Zeinab Fathy, Nesreen Abd El Wahab

Discussion: secondary schools provide the community

with large number of nursing graduates than
Globally in (2012), there were 15 million other agencies such as faculties and technical
infants born prematurely. The majority of institutes of nursing.
premature infants occur in resource-poor
countries including India, Nigeria, Pakistan, and Regarding the years of experience of the
the Democratic Republic of Congo, where studied nurses, the present study showed that
many die due to the lack of basic skilled near half of them had 1 > 5 years of
nursing care. experiences in NICUs with mean years of
experiences of 6.04 ± 2.88 years. This
The aim of the current study was to assess finding was similar to the findings of
neonatal nurses‟ knowledge and practice Kunswa (2010), in the study "Needs,
regarding maternal kangaroo care (MKC) that problems and nursing care of newborn
consequently can help in providing better infant", who found that the majority of the
quality of care and overcoming the possible studied nurses had years of experience from
barriers hindering MKC for neonates at the 5-10 years with a mean of 5.5 ± 3.01 years.
neonatal intensive care units (NICUs). The
study was carried out at the NICUs of the According to the National Association
children's hospital, affiliated to Ain Shams of Neonatal Nurses NANN (2012), the years
university hospitals. of experience in the NICU had a significant
effect on the nurses‟ knowledge and
In the present study, the socio- performance, which resulted in improving the
demographic characteristics of the studied quality and consistency of care provided to
nurses revealed that less than half of them the high-risk neonates.
were aged less than 25 years old. This result
agreed with that of a study done by Farouk The current study‟s results also showed
(2009), about the assessment of nursing care that the majority of the studied nurses did not
given for high risk neonates, and reported that attend any training courses related to
the nurses dealing with high risk neonates kangaroo care. These findings were
aged between 20 < 25 years. supported by Mustafa (2007) who found
that, the majority of the nurses did not attend
Regarding the gender of the studied training courses in NICU, and this might
nurses, the results of the present study affect their levels of knowledge and
showed that about two thirds of them were performance. Also, these results were similar
females. This finding was similar to the to those in the study done by Flynn and
results of Farouk (2009), who found that Leahy-Warren (2010), "Neonatal nurses‟
more than two thirds of the studied nurses knowledge and beliefs regarding kangaroo
were females. This may assure the idea that care with preterm infants" that included 75
the female nurses preferred working in neonatal nurses who implemented kangaroo
NICUs more than male nurses. care in their practical work and had a positive
belief about the method, it was showed that
Regarding the nurses‟ qualifications, it none of these nurses received any formal
was found that more than one third of them training or education in kangaroo care.
had nursing diplomas. This result agreed with
that of a study carried out by Abo Zaid According to the study of Carol (2009),
(2008), about the quality of nursing care to “Nurses, attendance of training courses for
high risk neonates receiving total parenteral caring of neonates in NSICU", the training
nutrition, which described that more than half programs play an important role in enhancing
of the studied nurses had nursing diplomas. and updating the nurses' knowledge and
This may be due to the fact that nursing practice, in addition to improving the quality

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 Assessment of Nurses' Knowledge and Practice Regarding to Kangroo Care at Neonatal
Intensive Care Unit (NICU)
of care given to the neonate. The researcher In the present study, the results revealed
believes that attending training programs by that less than half of the studied nurses believed
nurses, especially in the NICU and especially that kangaroo care decreased pain sensation in
in kangaroo care, is crucial to provide proper infants. This result was inconsistent with the
quality of nursing care for newborns. study done by McCord (2011), "Exploring
nurses‟ perceptions on the use of KMC to
Regarding assessing nurse‟s knowledge reduce pain", which found that the nurses
about prematurity, it was found that about appeared to be empathetic to the fact that
two thirds of them had satisfactory infants in the NICU experienced pain and
knowledge about premature newborn infants. believed that KMC can reduce the pain-
This result was inconsistent with the study of related procedures.
Abdel-Hamid (2007), "Effect of the quality
of nursing care on the preterm neonate‟s in Regarding the nurses‟ knowledge about
incubator" which stated that more than half the benefits of kangaroo care for the mother, the
of the nurses had poor knowledge about findings of the current study showed that the
premature infants. minority believed that KMC increased
breastfeeding. This result was inconsistent
Beal (2000), recommended that the with a study conducted by Singh and Yadav
nurses who assume responsibility for (2012), who found that the majority of the
premature infants should receive an advanced studied sample believed that KMC led to
neonatal orientation program before starting more effective breastfeeding. According to
work in NICUs. Hung and Berg (2014), kangaroo care is a
beneficial method for breast-feeding and
In the present study, less than half of the temperature control of all newborn infants.
studied nurses had proper knowledge
regarding the definition and correct position In the present study, near a quarter of
of kangaroo care. This result was similar to the studied nurses believed that KMC
that of Arohi et al. (2013), "Knowledge and increased bonding between mother and
attitude regarding KMC practice among infant. This result was inconsistent with the
healthcare providers", which illustrated that study conducted by Singh and Yadav
about one third of the studied nurses had (2012), who stated that kangaroo care
proper knowledge regarding the definition increased togetherness, improved the threat
and position of KMC. of separation, provided a sense of
containment and closeness; in addition,
Regarding the nurses‟ knowledge about mothers were more quickly adapted to the
the benefits of kangaroo care for premature appearance of their infants, and it
infants, the findings of the current study strengthened the mother's confidence in
showed that the nurses believed that KMC gaining emotional control.
increased the premature infant‟s body weight.
This finding was similar to those in the study According to Flacking et al. (2014),
conducted by George (2013), who found that kangaroo care facilitated bonding, enhanced
more than half of the studied subjects agreed the warm and loving sensation that comes
that KMC helped to increase infant‟s body with bonding and made the mother feel the
weight. Also, in the study of Flacking et al. affectionate relationship sooner with her
(2011b), "The benefits of kangaroo care", it infant. In a similar study, Wallace and
was stated that infants on KMC had better Marchall (2001) found that skin to skin
weight gain and, therefore were discharged contact between the mother and newborn
early. infant promoted maternal-neonate
attachment.

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 Wafaa El Sayed Ouda, Zeinab Fathy, Nesreen Abd El Wahab

It was found by Charpak et al. (2010), be raised and updated to encourage mother‟s
that mothers in a kangaroo care group scored practice of such technique.
more favorably on the sense of competence,
feelings of worry or stress, sensitivity, and This view was supported by the study of
infant's responsiveness. Moreover, the total Chan et al. (2016), "Investigating the factors
attachment scores determined through influencing the adoption of KMC in different
structured interviews by Gathwala et al. (2012) contexts" and another study by Ramaiah
were higher in the kangaroo care group than in (2016), that was conducted at Umm-Al Qura
controls. University, and found that nurses had
inadequate knowledge regarding KMC.
Regarding the nurses‟ knowledge According to the study of El Zaidy et al.
related to the obstacles of kangaroo care, the (2017), "Effect of family centered
results clarified that near half of them developmental care program on nurses
reported that the place in NICU was not working at NICUs" the nurses‟ knowledge
suitable for applying kangaroo care. This regarding MKC can improved significantly
result was similar to that in the study done by with educational programs and guidelines.
Olsson et al. (2012), about NICU nurses‟
ambivalent attitudes in skin-to-skin care On assessing nurse‟s practice regarding
practice, which illustrated that the staff kangaroo care, the current study clarified that
members working in NICUs considered the less than half of them had satisfactory levels
lack of space in the intensive care room an of practice regarding kangaroo care. This
important barrier in applying kangaroo care. result was in disagreement with the study
done by George (2013), who found that the
Also, these results were similar to those majority of the studied subjects had good
in the study conducted by McCord (2011), scores related to the practice of kangaroo care
who found that more than half of the nurses technique.
identified an array of context-related issues in
the NICUs that included increased workload, Furthermore, the results in the current
inadequate physical space, poor lighting and study found that there were statistically
lack of privacy. significant differences between the total
knowledge of the studied nurses and their age,
From the researchers‟ point of view, educational level, years of experience in NICU
sometimes the shortage in supplies and and previous training in kangaroo care with P-
facilities leads to inadequacy in nursing care value (< 0.05).
in this aspect.
In a similar study done by Arohi et al.
Regarding the nurses‟ knowledge about (2013), "Knowledge and attitude regarding
the nursing role in kangaroo care, the current KMC practice among healthcare providers in
study illustrated that the majority had good India", there was a statistically significant
levels of knowledge. This result was similar association between the knowledge related to
to that in the study done by Chia et al. KMC and HCPs training (P < 0.0001), while
(2006), about the attitudes and practices of the association between their total scores and
neonatal nurses in the use of kangaroo care, education or experience was statistically
where the majority of the nurses had good insignificant.
levels of knowledge and positive attitudes
towards the nursing role in kangaroo care. There was also a statistically
insignificant association between knowledge
The researcher believes that the nurse‟s scores and education. This shows that even if
knowledge regarding kangaroo care should the neonatal nurses were less educated, their
skills can be enhanced by imparting training.

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Intensive Care Unit (NICU)
Conclusion come the career and educational resource
for minority nursing professional, pp. 1-5.
Based on the findings and research
questions of the present study, it can be Chan, G.J., Labar, A. S., Wall. S. and Atuna,
R. (2016): Kangaroo mother care: A
concluded that most of the nurses had average
systemic review of barriers and enables.
knowledge regarding kangaroo care and less
Bulletin of the world health organization
than half of them had satisfactory practices (WHO), 94(2):130-141.
regarding kangaroo care.
Charpak, N., Ruiz-Peláez, J.G., Figueroa de,
Recommendations: C.Z. and Charpak, Y. (2010): Kangaroo
mother versus traditional care for newborn
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Chia, P., Sellick, K. and Gan, S. (2006): The
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Conde-Agudelo A, Belizan J and Diaz-

Preparing a well-equipped room with
Rosselo J (2011): Kangaroo mother care to
warming and comforting needs for premature
reduce morbidity and mortality in low
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