Rita Pace Parascandalo

Reviewing the literature is the starting point for most research studies.

Since the 1990s the systematic review (SR) has been developed.

The main purpose of a SR is to inform practice and policy and identify gaps in the knowledge.

SR initially focused on quantitative studies, specifically RCTs, and included meta-analysis of data.

Qualitative research could also be reviewed and synthesised, with the aim of providing greater understanding of a phenomenon.

SR have developed in response to a growing need for policy makers, researchers and practitioners to have access to the latest research evidence when making decisions.

More recent advances have led to mixing methods at the review level

Integrating the findings of multiple, already existing studies that are labelled broadly as using either ‘qualitative’ or ‘quantitative’ methods.

SR adopt rigorous methods.

Traditionally, SR have been used most often to answer questions of effectiveness – ‘What works?’

Reviews that go beyond such questions are newer, and often bring together data from both ‘qualitative’ and ‘quantitative’ studies.

Methods for reviewing both qualitative and quantitative studies in a systematic way are still emerging.

‘What are the perspectives of neonatal staff and parents about the transition of preterm infants from the NICU to home?’

Studies designed to focus around NICU discharge preparation and /or transition to home of the preterm infant.

Studies where data has been collected on approaching discharge towards the end of the NICU hospitalisation and /or in the first six months after discharge.

Studies where the infants were discharged home without the requirement of any special care (e.g. apnoea monitors, oxygen therapy, etc)

Studies where the parents are the primary caregivers at home.

Studies where NICU discharge was according to standard procedures.

Studies done in any country, published in any language, using any research design and published from 1990 till present.

Full-text studies are published and accessible.

Studies which are restricted to focus on particular aspects relating to preterm birth e.g. psychological distress.

Abstracts from conferences, books and unpublished dissertations.

Studies published prior to January 1990.

Studies which focus only on the NICU hospitalisation period.

Studies focusing on specialised discharge procedures as in earlier NICU discharge.

An extensive literature search in numerous relevant databases was done.

Ovid Medline, PsycINFO, CINAHL, Cochrane Databases of Systematic Reviews, Academic Search Complete, BMJ Journals, EBSCOhost, BIOMED Collection, JSTOR, Sage Journals Online, Joanna Briggs Institute and Google Scholar.

Studies were also hand-searched.

The search for the literature was done between January and August 2011.

Keywords used included a combination of ‘discharge’ , ‘NICU’, ‘neonatal intensive care’, ‘parent’, ‘staff’, ‘transition’, ‘preterm’.

Synonyms and alternative words / terms to these identified keywords have also been searched.

Using the identified key words and their synonyms or alternative words, two separate literature searches were done; one for neonatal staff and another for the parents.

For each search key words were attributed to four main areas: population, topic, orientation and context.

Boolean searches were then carried out to combine keywords to be searched for each of the four main areas.

Population Topic Orientation Context

Staff

OR

Discharge Planning

OR

Perceptions

OR

Preterm

OR

Nurses

OR

Discharge preparation

OR

Views

OR

Premature

Or

Midwives

OR

Discharge practices

OR

Perspectives

OR

NICU

165 potentially relevant search results

28 were empirical studies which clearly or loosely met the inclusion criteria.

Qualitative studies, n=8, included

Quantitative studies, n= 9, included

Ambiguous studies, n=11, 10 excluded, 1 awaiting english translation

Focus mainly on stress

Unclear when exactly data was collected

Main focus was on the hospitalisation period

Aim of study not reflected in the findings.

Qualitative studies:Qualitative descriptive 5

(US, UK, Korea, Brazil{2})

Phenomenology 3(Sweden, Canada, USA)

Quantitative studies:Descriptive Survey 9(Scotland, England, USA {3}, Canada {2}, Israel

{2})

Quality assessment for qualitative studies utilising the tool developed by Downe et al (2007)

For each study, questions are answered usingY=yes, N=no or UC=unclear Each study is graded using the following grading

system:A: No, or few flaws; quality is highB: Some flaws unlikely to affect qualityC: Some flaws that may affect qualityD: Significant flaws that very likely affect quality

Author, Year & Country

Aims: Clear?

Participants:Appropriate for aims & theoretical perspective?

Design: appropriate for aims & theoretical perspective?

Methods:Appropriate for design?

Sample: size and sampling justified?

Does the data analysis fit with the chosen methodology?

Reflexivity present?

Study ethical?

Do the data presented justify the findings?

Is the context described sufficiently?

Is there sufficient evidence of rigour?

Quality grade

Overall qualitative studies were of average to low quality (2 B, 3C, 3D)

A theoretical perspective and reflexivity were not evident in any of the studies.

Research design not justified. Details for recruitment were lacking. Limited aspects of rigour discussed. Lack in other important details; inclusion

criteria and sampling, characteristics of the sample, context of the study.

Utilised a self-designed tool for appraisal of survey studies.

For each study, questions are answered usingY=yes, N=no or UC=unclear Each study is graded using the following

grading system:A: no, or few flaws, quality is highB: some flaws, unlikely to affect qualityC:some flaws, that may affect qualityD:significant flaws, likely to affect quality

Author, Year & country

Aims: clear?

Design: appropriate & justified?

Methods & research tool: clear, appropriate for design?

Participants: appropriate for question?

Sample: size and sampling clear, appropriate & justified?

Methods & tests used for data analysis: clear & justified?

Study ethical?

Do the data presented justify the findings?

Is the context described sufficiently?

Is there sufficient evidence of validity & reliability?

Quality grade

Overall quantitative studies were of average to low quality (4 B, 4 C, 1D)

Majority were small scale studies with non random convenience sampling

Design not justified Recruitment and sampling not clear Limited discussion on issues of validity and

reliability

Study participants:Mothers onlyParents – but results reflect maternal responsesParents – collectively, no distinction between

maternal and paternal responsesParents – responses are distinguised between

mothers and fathers

Sample sizes:6 – 47 mothers and 7 – 10 sets of parents

Sampling methods:Mainly purposiveIn some studies sampling is not clear

Data collection: Methods – semi-structured to unstructured

interviews and focus groups Timing – Range between one time data collection to

longitudinal collection up to five timesStarting from prior discharge, at time of discharge

and up to 6 months after discharge

Data analysis:

Content analysis (Miles & Huberman, 1994)Thematic content analysis (Bardin, 2000)Colaizzi’s (1978) methodGiorgi’s (1985, 2000) method

Study participants:Mothers onlyNeonatal nurses and mothersParents – but results reflect maternal

responsesParents – collectively, no distinction between

maternal and paternal responsesParents – results distinguished between

mothers and fathers

Sample sizes:7 – 34 nurses45 – 56 mothers10 -80 sets of parents867 family-nurse pairs

Sampling methods:Non-random convenience Unclear

Data collection: Methods – self-administered /

face-to-face/telephone questionnaires- Self-designed / standard tools

Timing – from one day before discharge to three months post discharge

Data anlaysis:Descriptive and /or inferential statistics

Findings that contributed to answering the review question were extracted from the studies.

Studies included in this review can be termed ‘descriptive studies’ where perpectives or experiences of participants are elicited from both the quantitative and qualitative paradigms.

These kind of studies are also called ‘views’ studies.

A descriptive thematic analysis was done separately for the qualitative and quantitative studies.

The descriptive themes and their essential features were examined in the light of the review question to infer the perspectives of neonatal staff and parents.

Main Themes Sub-themes Theme components

Parental emotional responses to baby’s discharge home

Changes over time in parental mixed feelings

Positive and negative feelings: upon discharge, at 1 – 4 months post discharge, at 4- 6 months, at 6 months

Preparation and instructions for discharge

Factors predisposing to parental readiness for discharge

Parental reactions to preparations for discharge

Parental participation in infant care during hospitalisation

Various indications of being ready to go home

Negative and positve aspects

Active vs limited involvement in care

Preparation and instructions for discharge (cont)

Professional support and information needs indicated by parents

Factors affecting parental learning on the NICU

Ongoing support and teaching need in various identified areas.

Deficits in information giving

Realities of caring for the preterm baby at home

Maternal and paternal concerns for baby

Difficulties relating to parental roles

Physical and psychological effects of parenting

Adjusting to a lifestyle that included the baby

Maternal ways of coping

Various expressions of mothers and fathers concernsVarious identified difficulties

Maternal and paternal effects

Various changes in lifestyle identified

Self-support, communication & accepting support

Main themes Sub-themes Theme components

Discharge teaching Importance and content

Responsibility for discharge teaching

Unmet parental informational needs

Discharge preparedness perspectives

Importance & content of topics not always agreed by staff and parents

Staff perspectives

Topics lacking adequate information

Staff and parents

Sources of information and support

Prior discharge

Following dischargeDifferent personnel mentioned

Main theme Sub-themes Theme components

Parental feelings (at 2 – 3 months after discharge)

Mothers’ sense of competence and stress/anxiety

Fathers’ sense of competence and stress/anxiety

Different levels of competence and stress/anxiety identified

??????

Possibly a comparative synthesis guided by the following questions:

What are perspectives focused on in the quantitative and qualitative studies?

Which perspectives are similar / different across both types of studies?

What areas have not been addressed in such studies so far?