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Environmental Privacy in an Open-Bay Neonatal Intensive Care Unit

Permanent Link: http://ufdc.ufl.edu/UFE0043806/00001

Material Information

Title: Environmental Privacy in an Open-Bay Neonatal Intensive Care Unit a Case Study of Bedside Space for Lactating Mothers
Physical Description: 1 online resource (137 p.)
Language: english
Creator: Price, Jeannette M
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2011

Subjects

Subjects / Keywords: bedside -- controllability -- coping -- design -- healthcare -- lactation -- mother -- nicu -- privacy -- stress
Interior Design -- Dissertations, Academic -- UF
Genre: Interior Design thesis, M.I.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Over 400,000 babies are admitted to a neonatal intensive care unit (NICU) each year in the United States where premature and critically ill newborns are given intensive medical attention. Hospitalization of a newborn is recognized by families and caregivers alike as being inherently difficult, emotional and stressful. The addition of environmental stressors while in the unit further increases parents' perceived stress. Yet, it has been established that having a sense of control with respect to potential environmental stressors can markedly reduce or even eliminate its negative effects. The challenge is for NICU designers and staff to provide mothers with the necessary tools and support to be able to supply their valuable breast milk, while simultaneously attempting to establish a relationship with their infant. Breastfeeding facilitates mother-infant bonding and reduces rates of physical diseases. Lactation and bonding activities require environmental privacy which involves individual privacy control. To feel comfortable performing activities such as skin-to-skin contact, milk expression and breastfeeding, mothers need to have control of individual privacy mechanisms. There is a need to explore the specific contribution that the physical environment of the NICU may play in this process. This study addresses the behavioral patterns, opinions and desires of mothers in an open-bay NICU environment. Included in the study are mothers of infants currently admitted to the NICU that have at least attempted to express milk or breastfeed at their infant's bedside. The mother's options for spatial, visual and auditory privacy are reviewed by observation, interview and questionnaire, while the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU) rating scale is utilized to judge whether environmental privacy issues are contributing additional stress to the individuals. Findings indicate that the Level III NICU utilized in this study achieved more of the recommended standards for environmental privacy design than NICU II, yet noise in both units impacted lactating mothers more than any other environmental privacy factor due to this being the issue over which they have the least amount of controllability. Overall privacy findings indicate that the lactating mothers' perceived control of their environmental privacy conditions does affect their overall experience in an open-bay NICU, as over half did not achieve their desired privacy level. However, the connection between environmental privacy design and the mothers' perceived levels of stress was unable to be made through the use of the parental stressor scale. Despite this, the perceived stress levels recorded were similar among study participants in both units which indicates the participants were not affected by the environmental privacy design at their infant's bedside as much as other stressors in an open-bay NICU. Results from this study contain implications for NICU designers and staff to assist in the promotion of the parental role through control of the built environment to gain privacy and reduce the effects of environmental stressors. In the future, particular attention needs to be directed towards placement of the mothers within the open-bay unit according to their internal psychology, which plays a role in how the individual copes with environmental stressors. Mothers should also be afforded individual control of the spatial and visual privacy mechanisms at the infant's bedside in order to feel comfortable performing intimate activities such as breastfeeding. This sense of control was proven to be an important factor that influenced the mother's stress level and contributed to mother-infant bonding. Finally, it is important that auditory privacy strategies remain in the forefront of NICU design since unwanted environmental sounds were reported to have a negative effect on the individuals when attempting to perform lactation which requires relaxation.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Jeannette M Price.
Thesis: Thesis (M.I.D.)--University of Florida, 2011.
Local: Adviser: Torres Antonini, Maruja A.
Local: Co-adviser: Carmel-Gilfilen, Candy.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2011
System ID: UFE0043806:00001

Permanent Link: http://ufdc.ufl.edu/UFE0043806/00001

Material Information

Title: Environmental Privacy in an Open-Bay Neonatal Intensive Care Unit a Case Study of Bedside Space for Lactating Mothers
Physical Description: 1 online resource (137 p.)
Language: english
Creator: Price, Jeannette M
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2011

Subjects

Subjects / Keywords: bedside -- controllability -- coping -- design -- healthcare -- lactation -- mother -- nicu -- privacy -- stress
Interior Design -- Dissertations, Academic -- UF
Genre: Interior Design thesis, M.I.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Over 400,000 babies are admitted to a neonatal intensive care unit (NICU) each year in the United States where premature and critically ill newborns are given intensive medical attention. Hospitalization of a newborn is recognized by families and caregivers alike as being inherently difficult, emotional and stressful. The addition of environmental stressors while in the unit further increases parents' perceived stress. Yet, it has been established that having a sense of control with respect to potential environmental stressors can markedly reduce or even eliminate its negative effects. The challenge is for NICU designers and staff to provide mothers with the necessary tools and support to be able to supply their valuable breast milk, while simultaneously attempting to establish a relationship with their infant. Breastfeeding facilitates mother-infant bonding and reduces rates of physical diseases. Lactation and bonding activities require environmental privacy which involves individual privacy control. To feel comfortable performing activities such as skin-to-skin contact, milk expression and breastfeeding, mothers need to have control of individual privacy mechanisms. There is a need to explore the specific contribution that the physical environment of the NICU may play in this process. This study addresses the behavioral patterns, opinions and desires of mothers in an open-bay NICU environment. Included in the study are mothers of infants currently admitted to the NICU that have at least attempted to express milk or breastfeed at their infant's bedside. The mother's options for spatial, visual and auditory privacy are reviewed by observation, interview and questionnaire, while the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU) rating scale is utilized to judge whether environmental privacy issues are contributing additional stress to the individuals. Findings indicate that the Level III NICU utilized in this study achieved more of the recommended standards for environmental privacy design than NICU II, yet noise in both units impacted lactating mothers more than any other environmental privacy factor due to this being the issue over which they have the least amount of controllability. Overall privacy findings indicate that the lactating mothers' perceived control of their environmental privacy conditions does affect their overall experience in an open-bay NICU, as over half did not achieve their desired privacy level. However, the connection between environmental privacy design and the mothers' perceived levels of stress was unable to be made through the use of the parental stressor scale. Despite this, the perceived stress levels recorded were similar among study participants in both units which indicates the participants were not affected by the environmental privacy design at their infant's bedside as much as other stressors in an open-bay NICU. Results from this study contain implications for NICU designers and staff to assist in the promotion of the parental role through control of the built environment to gain privacy and reduce the effects of environmental stressors. In the future, particular attention needs to be directed towards placement of the mothers within the open-bay unit according to their internal psychology, which plays a role in how the individual copes with environmental stressors. Mothers should also be afforded individual control of the spatial and visual privacy mechanisms at the infant's bedside in order to feel comfortable performing intimate activities such as breastfeeding. This sense of control was proven to be an important factor that influenced the mother's stress level and contributed to mother-infant bonding. Finally, it is important that auditory privacy strategies remain in the forefront of NICU design since unwanted environmental sounds were reported to have a negative effect on the individuals when attempting to perform lactation which requires relaxation.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Jeannette M Price.
Thesis: Thesis (M.I.D.)--University of Florida, 2011.
Local: Adviser: Torres Antonini, Maruja A.
Local: Co-adviser: Carmel-Gilfilen, Candy.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2011
System ID: UFE0043806:00001


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1 ENVIRONMENTAL PRIVACY IN AN OPEN BAY NEONATAL INTENSIVE CARE UNIT: A CASE STUDY OF BEDSIDE SPACE FOR LACTATING MOTHERS By JEANNETTE M. PRICE A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIA L FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF INTERIOR DESIGN UNIVERSITY OF FLORIDA 2011

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2 2011 Jeannette M. Price

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3 To my family with love

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4 ACKNOWLEDGMENTS I would like to extend my sincerest thank s to Dr. Maruja Torres Ant onini my committee chair, for her guidance support and encouragement throughout this process I would also like to thank Professor Candy Carmel Gilfilen, my co chair, for her thoughtful critiques and wordsmithing The teachings of these two professors h ave been invaluable throughout my career as a design student and it is remarkable how well they balance each instruction. Without t heir advice and dedication, this document may never have been completed. A s pecial thanks to Dr. Leslie Parker for as sisting me throughout my research ; especially for the time spent in the neonatal intensive care unit ( NICU ) collecting data. Her tim e, effort and encouragement are very much appreciated I would also like to thank Drs. James and Sandra Sullivan for their r ole in establishing the connection with the Department of Interior Design to conduct research at Shands NICU. I would like to thank Shands Hospital at the University of Florida for allowing me to collect information about the design of the ir interior. I w ould also like to thank the staff of Shands NICU for their hospitality and for allowing me to use their workplace for my research I am especially thankful for all of the participants who contributed to this study for their honest responses and willing par ticipation. Finally, I would like to thank my family and friends, especially my parents, Davide and Jac kie Price, for all of their love and support. I could not have d one this without them

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5 TABLE OF CONTENTS page ACKNO WLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 8 LIST OF FIGURES ................................ ................................ ................................ .......... 9 LIST OF ABBREVIA TIONS ................................ ................................ ........................... 11 ABSTRACT ................................ ................................ ................................ ................... 12 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 15 Purpose of the St udy ................................ ................................ .............................. 19 Scope of the Study ................................ ................................ ................................ 20 2 LITERATURE REVIEW ................................ ................................ .......................... 21 Introduction ................................ ................................ ................................ ............. 21 Lactation in the Neonatal Intensive Care Unit ................................ ......................... 21 Decision to Breastfeed ................................ ................................ ..................... 22 Milk Expression ................................ ................................ ................................ 23 Breastfeeding ................................ ................................ ................................ ... 24 Skin to Skin Care ................................ ................................ ............................. 24 Family Centered Care ................................ ................................ ...................... 25 ................................ ................................ ................................ 25 Environment for Mother and Infant ................................ ................................ ......... 27 Environmental Stressors ................................ ................................ .................. 27 Environmental Privacy ................................ ................................ ...................... 28 Personal Space ................................ ................................ ................................ 29 Privacy Control ................................ ................................ ................................ 31 NICU Design ................................ ................................ ................................ ........... 34 Conclusion ................................ ................................ ................................ .............. 37 3 RESEARCH METHODOLOGY ................................ ................................ ............... 38 Research Study Design ................................ ................................ .......................... 38 Theoretical Framework ................................ ................................ ........................... 39 Setting ................................ ................................ ................................ ..................... 42 Study Instruments ................................ ................................ ................................ ... 48 Sampling Procedure ................................ ................................ ............................... 52 Data Collection ................................ ................................ ................................ ....... 52 Informed Consent ................................ ................................ ............................. 52

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6 Questionnaire ................................ ................................ ................................ ... 53 Interview ................................ ................................ ................................ ........... 53 Sample ................................ ................................ ................................ .................... 54 Data Analysis ................................ ................................ ................................ .......... 56 Limitations ................................ ................................ ................................ ............... 57 Assumptions ................................ ................................ ................................ ........... 57 4 FINDINGS ................................ ................................ ................................ ............... 58 ................................ ................................ ................................ ....... 58 Lactation ................................ ................................ ................................ ........... 59 Lactation ability ................................ ................................ .......................... 59 Distraction ................................ ................................ ................................ .. 60 Maternal Stress ................................ ................................ ................................ 61 Previous experience ................................ ................................ .................. 61 Internal psychology ................................ ................................ .................... 62 Neonatal intensive care unit experiences ................................ .................. 63 Environmental Privacy ................................ ................................ ............................ 68 Environmental Stressors ................................ ................................ .................. 68 The unit design ................................ ................................ .......................... 69 Spatial orientation and circulation ................................ .............................. 72 Copi ng with Environmental Stressors ................................ ............................... 74 Spatial privacy ................................ ................................ ............................ 75 Visual privacy ................................ ................................ ............................. 79 Auditory privacy ................................ ................................ ......................... 81 Overall privacy ................................ ................................ ........................... 83 Conclusion ................................ ................................ ................................ .............. 84 5 D ISCUSSION ................................ ................................ ................................ ......... 86 ................................ ................................ ................................ ....... 88 Maternal Characteristics ................................ ................................ ................... 88 Tim e in the neonatal intensive care unit ................................ ..................... 88 Lactation ................................ ................................ ................................ .... 89 Maternal Stress ................................ ................................ ................................ 90 Previous experience ................................ ................................ .................. 90 Internal psychology ................................ ................................ .................... 91 Neonatal intensive care unit experiences ................................ .................. 92 Overall stressor scores ................................ ................................ .............. 94 Environmental Privacy ................................ ................................ ............................ 97 Frequent Issues ................................ ................................ ................................ 97 Spatial configuration ................................ ................................ .................. 98 Spatial orientation ................................ ................................ .................... 101 Spatial privacy ................................ ................................ .......................... 101 Visual privacy ................................ ................................ ........................... 103 Auditory privacy ................................ ................................ ....................... 104 Location in the Unit ................................ ................................ ......................... 105

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7 Staff Accommodation ................................ ................................ ..................... 107 Recommendations for Environmental Privacy and Comfort ................................ .. 108 ................................ ................................ ..................... 108 Spatial and Visual Privacy ................................ ................................ .............. 109 Auditory Privacy ................................ ................................ ............................. 111 Furniture ................................ ................................ ................................ ......... 113 Implications for Future Research ................................ ................................ .......... 115 Conclusion ................................ ................................ ................................ ............ 116 APPENDIX A INSTITUTIONAL REVIEW BOARD LETTER OF APPROVAL ............................. 118 B INFORMED CONSENT DOCUMENT ................................ ................................ ... 119 C CERTIFICATE OF C OMPLETION FOR HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT & PRIVACY RESEARCH ................................ ... 121 D PERMISSION TO USE PARENTAL STRESSOR SCALE: NEONATAL INTENSIVE CARE UNIT RESEARCH INSTRUMENT ................................ ......... 122 E INTERVIEW QUESTIONS ................................ ................................ .................... 123 F PARTICIPANT QUESTIONNAIRE ................................ ................................ ....... 126 LIST OF R EFERENCES ................................ ................................ ............................. 130 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 137

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8 LIST OF TABLES Table page 3 1 Participant ag e ................................ ................................ ................................ .... 54 3 2 Marital status ................................ ................................ ................................ ...... 55 3 3 Years of school completed ................................ ................................ ................. 55 3 4 Employment ................................ ................................ ................................ ........ 55 3 5 Combined family income ................................ ................................ .................... 55 4 1 Average length of time participants spent in the Neonatal Intensive Ca re Unit per day ................................ ................................ ................................ ............... 59 4 2 .................. 60 4 3 Previous child rearing and lactation experience and how each relates to overall stressfulness of the Neonatal Intensive Care Unit environment .............. 62 4 4 Average rating of stressors and frequency of participant experience from the Parental Stressor Scale : Neonatal Intensive Care Unit ................................ ...... 64

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9 LIST OF FIGURES Figure page 3 1 ................................ ................................ .............. 40 3 2 ................................ ................... 41 3 3 Level III Neonatal Intensive Care Unit floor plan ................................ ............... 46 3 4 Level II Neonatal Intensive Care Unit floor plan ................................ ................ 46 3 5 Furniture examples similar to those found in both NICUs. A) recl iner chair B) rocking c hair, C) office chair and D) nursing stool. ................................ ............. 47 3 6 Behavioral maps with location of each participant. A) Neonatal Intensive Care Unit III and B) Neonatal Intensive Care Unit II. ................................ .......... 51 4 1 Participants with previous experience. A) With other children. B) With lactation experience. ................................ ................................ ........................... 61 4 2 Extroverted versus introverte d internal psychology. ................................ ........... 62 4 3 Overall stress level rating of introverts and extroverts. ................................ ....... 63 4 4 Behavioral map of Sights and Sounds category scores. A) Neonatal Intensive Care Unit III and B) Neonatal Intensive Care Unit II. ................................ .......... 66 4 5 Order of stressors by average Parental Stressor Scale : Neonatal Intensive Care Unit score per experience. ................................ ................................ ......... 67 4 6 Content analysis of participant utterances regarding environmental stressors ... 69 4 7 Behavioral Neonatal Intensive Care Unit III and B) Neonatal Intensive Care Unit II. ........................... 73 4 8 Behavioral map of visitor and staff circulation. A ) Neonatal Intensive Care Unit III and B) Neonatal Intensive Care Unit II. ................................ ................... 74 4 9 Content analysis of participant utterances related to coping with environmental stressors ................................ ................................ ..................... 75 4 10 Utterance analysis of participant interviews which relate to spatial controllability ................................ ................................ ................................ ....... 78 4 11 Privacy screen similar to those found in both NICUs. ................................ ......... 78

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10 5 1 Location of participants with the highest overall Parental Stressor Scale : Neonatal Intensive Care Unit scores. A) Neonatal Intensive Care Unit III and B) Neonatal Intensi ve Care Unit II. ................................ ................................ ..... 97 5 2 Environmental Privacy Issues in Neonatal Intensive Care Unit II. .................... 106 5 3 Cloud shaped translucent pa rtition. ................................ ................................ .. 110 5 4 Similar cushion for existing rocking chairs. ................................ ....................... 114

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11 LIST OF ABBREVIATION S CDC Center s for Disease Control and Prevention CPR Cardiopulmonary R esuscitation EBD Evidence Based Design HIPAA Health Insurance Portability and Accountability Act IRB Institutional Review Board LPN Licensed Practical Nurse MBTI Meyers Briggs Type Indicator NICU Neonatal Intensive Care Unit PSS: NICU Parental Stressor Sca le: Neonatal Intensive Care Unit SFR Single F amily Room

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12 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Interior Design ENVIRONMEN TAL PRIVACY IN AN OPEN BAY NEONATAL INTENSIVE CARE UNIT: A CASE STUDY OF BEDSIDE SPACE FOR LACTATING MOTHERS By Jeannette M. Price December 2011 Chair: Mar u ja Torres Antonini Co C hair: Candy Carmel Gilfilen Major: Interior Design Over 400,000 babies a re admitted to a neonatal intensive care unit (NICU) each year in the United States where premature and critically ill newborns are given intensive medical attention. Hospitalization of a newborn is recognized by families and caregivers alike as being inhe rently difficult, emotional and stressful. The addition of environmental established that having a sense of control with respect to potential environmental stressors can markedly reduce or even eliminate its negative effects. The challenge is for NICU designers and staff to provide mothers with the necessary tools and support to be able to supply their valuable breast milk, while simultaneously attempting to establish a relationship with their infant Breastfeeding facilitates mother infant bonding and reduces rates of physical diseases Lactation and bonding activities require environmental privacy which involves individual privacy control To feel comfortable perform ing activities such as skin to skin contact, milk expression and breastfeeding mothers need to have control of individual privacy

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13 mechanisms. There is a need to explore the specific contribution that the physical environment of the NICU may play in this p rocess. This study addresses the behavioral patterns, opinions and desires of mothers in an open bay NICU environment. Included in the study are mothers of infants currently admitted to the NICU that have at least attempted to express milk or breastfeed a t their reviewed by observation, interview and questionnaire, while the Parental Stressor Scale: Neonatal Intensive Care Unit ( PSS: NICU ) rating scale is utilized to judge w hether environmental privacy issues are contributing additional stress to the individuals. Findings indicate that the Level III NICU utilized in this study achieved more of the recommended standards for environmental privacy design than NICU II, yet noise in both units impacted lactating mothers more than any other environmental privacy factor due to this being the issue over which they have the least amount of controllability. of their environmental privacy conditions does affect their overall experience in an open bay NICU, as over half did not achieve their desired privacy level. However, the connection stress was unable to be made through the use of the parental stressor scale. Despite this, the perceived stress levels recorded were similar among study participants in both units which indicates the participants were not affected by the environmental priv acy design bay NICU. Results from this s tudy contain implications for NICU designers and staff to assist in the promotion of the parental role through control of the built environment to gain

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14 privacy and reduce the effects of environmental stressors. In the future, particular attention needs to be directed towards placement of the mothers within the open bay unit according to their internal psychology, which plays a role in how the individual copes with environmental stressors. Mothers should also be afforded individual control comfortable performing intimate activities such as breastfeeding. This sense of con trol contributed to mother infant bonding. Finally, it is important that auditory privacy strategies remain in the forefront of NICU design since unwanted environmental soun ds were reported to have a negative effect on the individuals when attempting to perform lactation which requires relaxation.

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15 CHAPTER 1 INTRODUCTION Over 400,000 babies are admitted to a neonatal intensive care unit (NICU) each year in the United States (Cooper, Gooding, Gallagher, Sternesky, Ledsky & Berns, 2007; Prematurity Campaign, 2011). A NICU is the part of any hospital where premature infants infants born before the 37th week of pregnancy or have a birth weight of less than 5.5 pounds and cri tically ill newborns are given intensive medical attention (Neonatal Intensive Care Unit, 2009). According to the March of Dimes Prematurity Campaign, infants born preterm are at risk of severe health problems and lifelong disabilities, as 12.7 percent of births in this country are born at least three weeks before full term (Gorman, Aguayo, Bjerklie, Cuadros & Whitaker, 2004; Masters, 2006; Park, 2009). In addition, the premature birth rate has risen by 36 percent over the last 25 years (Prematurity Campai gn) due, in part, to the introduction of modern fertility treatments which caused a spike in the number of multiple births, such as twins and triplets, who were born early (Masters). Conversely, 83 percent of premature infants were single premature births that may have been caused by factors such as bacterial infections, high blood pressure, stress, smoking or alcohol consumption (Masters). Although these premature birth statistics are higher than most health experts would like, Gorman et al. (2004) remind us that advances in neonatal care have saved many infants who might have otherwise died; most of which grow up to be healthy adults. In addition neonatal specialists can ensure that 95 percent of preterm infants will survive (Masters, 2006) considering the current combination of specialized neonatal care and increased parent child interaction

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16 Forcada Guex, Pierrehumbert, Borghini, Moessinger and Muller Nix (2006) who compare preterm mother infant interaction patterns with term dyads, found that suppor t ing mother infant interactions can improve both behavioral and developmental outcomes of premature infants. Child Interaction Model also found the behaviors of parent and child, as well as environmental factors, to be critical determinant (Goeppinger & Fitzpatrick, 2000 ; Parent Child Interaction, 1996). child interaction is a predictor of later cognitive and language development of children at risk (Goeppinger & F itzpatrick ; Parent Child Interaction ). Breastfeeding is a form of mother infant interaction that is linked to improved brain development and better immunity in infants as well as a reduced cancer risk and less postpartum depression in mothers (Thean, 201 1) The Center s for Disease Control and Prevention (CDC) reports a steady increase in breastfeeding in the United States (Breastfeeding, 2011) Since 2007 the three month exclusive breastfeeding rate has increased more than five percent and the six month exclusive breastfeeding rate has improved more than four percent, yet the changes are not attributable to any single factor. ability to reach her breastfeeding goals can be influenced by her family, community, employer or health system. The CDC a lso reports that more than ever before, babies are being born in facilities that have made special ef forts to support breastfeeding as the hospital period is the critical period for mothers and infants to learn to breastfeed ( Breastfeeding ) When studying the effect NICU admission has on breastfeeding rate, Colaizy and Morriss (2008) found that admission to the NICU has a positive influence on breastfeeding continuation for mothers of preterm infants and

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17 improves the overall likelihood by ten percent. This means that mothers of premature infants admitted to the NICU were more likely to continue breastfeeding than mothers of non admitted infants ( Colaizy & Morriss ). In a literature summary which considers barriers inherent in current NICU design White (2004 ) explains that not all mothers feel that privacy is important for activities such as breastfeeding as long as the social setting of the NICU is supportive. Yet for many mothers fully engaging in skin to skin care and breastfeeding will only occur if the setting allows full privacy (White) In a summary of literature by Shepley (2004) which discusses design for infants and staff in the NICU, it is revealed that the more vulnerable the person is, the more sensitive they may be to a challenging physical env ironment. Therefore, difficulty during mother infant interaction s in the NICU such as breastfeeding, is stressful for mothers (Hughes McCollum Sheftel & Sanchez 1994; Perehudoff, 1990). nts which help NICU families cope with the stress ful experiences resulting in improved health outcomes: a sense of control with respect to physical social surroundings, access to social support, and access to positive distractions in physical surroundings (Ulrich, p. 99). As shown in Figure 1 1, these components can be translated into design related counterparts, or characteristics of the physical environment.

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18 Figure 1 1. Theory of Supportive Design and its design related counterparts. For families in a health care environment, sense of control is one of the most important factor s influencing stress level and wellness. Humans have a strong need for control and the related need of self efficacy with respect to environments and situations (Stewart Pollack & Menconi, 2005) A consistent finding in stress research has been that if an individual has a sense of control with respect to a potential stressor, the negative effects of the stressor are markedly reduced or even eliminated (Ulrich, 1991). For instance families desire environmental privacy for intimate interactions in a NICU setting, thus have a great need for privacy control (Altimier, 2004). Mothers in particular need to have control of privacy mechanisms to feel comfortable performing activities suc h as skin to skin contact, milk expression and breastfeeding (Brown & Taquino, 2001). In the last ten years, the design of many NICUs across the country has been moving from the open bay configuration or a n open room s upporting between ten to 50 infant b eds ( Shepley, Harris & White 2008) toward a single family room ( SFR ) layout or a series of private room s in which families have the option to stay at bedside continuously while the infant is being cared for ( Best Evidence Statement, 2011 ) This change is due in part to the relatively recent commitment to evidence based design

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19 (EBD) or the practice of basing built environment decisions on credible research to achieve the best possible result (Tannen, 2009) Studies conducted on this perspective determin ed that the active engagement of parents was most successful in the SFR configuration due to the provisions of increased environmental control and privacy (Domanico, Davis, Coleman & Davis, 2010) Even though an open bay unit also addresses environmental control and privacy concerns, it was still considered less successful by some (Harris, Shepley, White, Kolberg & Harrell, 2006; Johnson Abraham & Parrish 2004; Shepley et al. 2008). However, others determined that the open bay configuration to be bett er for staff communication and coworker access, mutual parental support, and decreased space and financial commitments for the hospital (Domanico et al ). in the promotion of a mot Yet t o date, the literature fails to focus on environmental privacy of the lactating mother in an open bay NICU design, and only a few studies give mention to the privacy mechanism s that are utilized for this process. T here fore, a study of the physical attributes of an open bay NICU was needed to illustrate how existing privacy mechanisms impact the user at the bedside This includes obtaining information from users to find out whether the configuration of the space contribu tes positively or negatively to their experience, and whether they observe an increased stress level due to the properties of the physical environment. Purpose of the Study This study explores the connection between environmental privacy design and perce bay NICU. As suggested by the literature, the study is based on the premise that a mother

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20 who is breastfeeding her infant should feel satisfied with the spatial, visual and audit ory privacy provided to her. Alternatively, she should be satisfied with the amount of control she can have over the physical environment if its conditions are not considered optimal. To this end, this study aims to answer the following questions : Does th e lactating l privacy conditions affect her overall experience in an open bay unit? To what extent, if any, does the physical environment of an open bay NICU impact the perceived stress of lactating mothers? Sc ope of the Study This study addresses the behavioral patterns, opinions and desires of mothers in an open bay NICU environment. Included in the study are mothers of infants currently admitted to the NICU that have at least attempted to express milk or brea stfeed at their s options for spatial, visual and auditory privacy are reviewed by observation, interview and questionnaire while a stressor rating scale is utilized to judge whether environmental privacy issues are contributi ng additional stress to the individuals.

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21 CHAPTER 2 LITERATURE REVIEW Introduction This review of literature covers existing infor mation relevant to the study of environmental privacy in a neonatal intensive care unit and the impact it has on lactating mo The review examines literature on lactation, skin to skin interaction family centered care, and the challenges that arise during the lactation process. L iterature about environmental privacy and controllability; personal spac e; neonatal intensive care unit ( NICU ) design and standards; open bay versus single family room design; and environmental stressors are also evaluated Lactation in the Neonatal Intensive Care Unit A very high value has been placed on breast milk and breas tfeeding for preterm infants (American Academy of Pediatrics, 2005; Furman, Minich & Hack, 2002 ; Schanler, 2001 ) as t he benefits of breastfeeding are both psychological and physical. Breastfeeding facilitates mother infant bonding and reduces rates of phy sical diseases, such as gastrointestinal disease, respiratory disease, asthma and some maternal cancers (Kervin, Kemp & Pulver, 2010). The challenge is for NICU staff to provide mothers with the necessary tools and support to be able to provide their valu able breast milk, while simultaneously attempting to establish a relationship with their infant (Hurst, 2007). Literature on lactation has focused on t he discussion of promotion and support location within the NICU and maternal challenges. Meier (2001) r eports that s uccessful breastfeeding promotion in the NICU environment requires that mothers receive adequate support and resources needed in order to overcome challenges such as

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22 separation, infant behaviors, and infant intolerance to feeding J ohnson et a l. (2004) state that e xpressing milk at the intervention that encourages mothers to provide milk until their infant is ready for breastfeeding. However, Jaeger, Lawson and Filteau ( 1997) argue that b r eastfeeding can be challenging for many women, even in the best of conditions and that f acilitation of breastfeeding in the NICU can be particularly difficult. A premature delivery, sick newborn, or any other unexpected pregnancy outcome may change the mo initial decision to breastfeed (Jaeger et al.) Decision to Breastfeed Literature on the decision to breastfeed is dominated by external variables that family and friends h ave a stronger influence on the decision to breastfeed than professional support while significant influence on the breastfeeding decision. Kong and Lee (2004) add that the amount of breastfeed ing knowledge a women has influences her decision as f eelings of responsibility, self worth and closeness with the infant impact the decision in fa vor of breastfeeding Conversely, an observational study performed by Furman et al. (2002) found that higher socioeconomic status was directly related to the decision to breastfeed and early and frequent milk ex pression In a study by Lessen and Crivelli Kovach (2007) where one hundred mothers were interviewed about nfant feeding it was found that mothers of most age groups intended to breastfeed exclusively. Many of the mothers reported that their decision to breastfeed was based on the health benefits for the infant. Others reasoned that breastfeeding is easier, mo re economical and

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23 promoted mother infant bonding. In contrast, some mothers initially had decided to breastfeed, but changed their minds due to either receiving maternal medications or blood products, exhibiting disproportionate stress levels or experienc ing a preterm breastfeed was mostly infant centered, while the decision to bottle feed was mostly mother centered (Lessen & Crivelli Kovach) Milk Expression For a mother planning to breastfeed, having her infant admitted to the NICU immediately following delivery can be difficult. Due to their size or condition, the infant cannot feed at the breast, so women must rely on a mechanical breast pump to initiate lactation and express milk Hurst (2007) report ed p umping to be a large, necessary part of the process to begin milk production when not initiated by the infant yet t he sensation s experience d during pumping to be very different from those experienced by mother s when br eastfeeding According to Hurst (2007) a during breastfeeding. For pump dependent mothers, demand is driven by her motivation to express her own milk while maintaining a level of milk production to meet her needs. Mechanical milk expression at the NICU bedside is possibly the best way to achieve this; by having the infant nearby to provide the cues associated with breastfeeding, such as sucking, smacking, cooing, and crying. These actions allow for breast stimulation which helps the mothers to develop a pumping schedule that sufficiently maintains an adequate milk volume (Hurst).

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24 Breastfeeding The literature on breastfeeding indicates that t he transition from expressing milk to breastfeeding the neo nate is challenging for many mothers. Lessen & Crivelli Kovach (2007) suggested that t o succeed in breastfeeding their hospitalized infant, a mother needs three things: increased support from family members, timely breastfeeding education, an d a supportive NICU environment. In the study performed by Lessen and Crivelli Kovach where one hundred mothers were interviewed regarding f actors influencing the initiation of breast feeding participants responded to questions regarding environmental factors in the NI CU that interfered with breastfeeding. Some of the respondents reported difficulty breastfeeding because of the inability to relax due to Kovach). Skin to Skin Care Fu rman and Kennell (2000) and Talmi and Harmon (2003) found few opportunities for relaxing and intimate interactions for parents with their hospitalized infant, which produced a great deal of stress and emotional turmoil for the parents. However, parents con sistently reported positive emotional effects of early, close physical contact with their newborn, such as that found through skin to skin contact (Furman & Kennell; Hurst, Valentine, Renfro, Burns & Ferlic, 1997; Johnson et al., 2004; Talmi & Harmon) Sk in to a technique of placing the infant which enhances a hormonal response that encourages lactation ( Browne, 2004; Hurst et al.; Johnson et al.) and aided the transition from gavage s and bottles to breastfeeding (Lessen & Crivelli Kovach, 2007).

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25 Family Centered Care Literature on f amily centered care reveals that it is becoming a standard of care in most NICUs. According to Brown and Taquino ( 2001 ), Cooper et al. ( 2007 ), and Fournier ( 1999) family centered care is a type of developmentally supportive care that source of strength and support Additionally it has been associated with numerous benefits including decreased length of stay, en hanced parent infant bonding improved well being of the pre term infant, better mental health outcomes and higher family s atisfaction (Cooper et al. ). Parker, Zahr, Cole and Brecht (1 992 ), Shepley (2002) and Zeskind and Lacino (1984) found that increased visita tion with the baby in the NICU results in a more realistic appraisal of the s to bonding Shepley (2002) contends that providing opportunities for such parent child interactions is critical In a literature summary by John son et al. (2004) which reviewed NICU designs for optimal involvement of family, it was concluded that a NICU environment which supports the active engagement of parents in the care encourages the parents to facilitate development of the child d uring and after hospitalization. Johnson et al. also found s trong positive evidence when observing practices in the NICU that reflect family centered care which include b reastfeeding support skin to skin contact and developmental care Mothers Stress Johnson et al. ( 2004 ) and Seideman, Watson, Corff, Odle, Haase & Bowerman (1997 ) reported c hallenging experiences in the NICU compound ed the stress levels in parents of premature, critically ill or low birth weight infants These experiences include d the altered appearance and behavior of the infant, a diminished parental role, and

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26 separation from the child. It was also suggested that t hese challeng ing experiences can have long term psychological effects that may hind er parent infant relationships Litera ture on these challenging experiences in the NICU is focused on the experience that caused the highest amount of perceived stress in NICU parents identified as top stresso rs, with Carter, Mulder and Darlow (2007) Dudek Shriber ( 2004 ) and Seidman et al. (1997) assigning the highest priority to the parental role alteration and Miles, Burchinal, Holditch Davis, Brunssen and Wilson (2002) to the or Miles et al. and Seidman et al. agree, however, about additional experiences that were highly stressful to parents These items include the inability to protect their child from pain, the inability to comfort or help witnessing needles put in the ir ch ild, and observing breathing problems (Miles et al.; Seidman et al. ) Spear, Leef, Epps and Locke (2002) stress indicating that mothers who were more stressed had less positive feelings towards their infant than l ess stressed mothers and that the likeliness to respond to infant cues was diminished if the mother was stressed. As a result of these behaviors, infants were less responsive and less likely to give clear cues to the mother (Spear et al. ). Additionally, S pear et al. determined that there did not appear to be an association ; the two are independent. However, it was found that t he p past experience s were the determin ing factor s for the degree o f maternal stress as f irst time motherhood lead to ineffectively cop ing with stress (Spear et al. ).

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27 Environment for Mother and Infant Literature on the p hysical aspects of healing environments determined that they play a posit ive role in the care giving process. Shepley (2004) recognized that clinical, operational and social aspects play the most significant role in healing, yet also identified the physical environment as a critical factor. Healing environments can be defined a s A more in depth definition is proposed by Stewart Pollack and Menconi (2005), who suggest that a healing environment is a positive physical enviro nment that incorporate s design elements providing comfort, security, stimulation, opportunities for privacy and control, positive distractions and access to a pa social support network In addition, Stewart Pollack and Menconi (2005) claim that a sense of control is one of the most important factor s influencing stress levels and wellness for families in a health care environment Sense of control, or controllability, can be defined as the perceived relationship between an individual and their envir onment. This relationship is essential for effective functioning as hu mans have a strong need for control and the related need of self efficacy with respect to environments and situations. When a wellbeing m ay be impervious to environmental stressors (Stewart Pollack & Menconi ) Environmental Stressors Literature on environmental stress from Devlin and Arneill (2003), Topf ( 1994 ), and Veitch and Arkkelin ( 1995) claim that e nvironmental stressors are long ter m conditions of the physical environment that are uncontrollable and may potentially result in stress or anxiety. These negative conditions of the environment include noise, density and

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28 unwanted observation (Devl in & Arneill ) Stewart Pollack and Menconi (2005) suggest that humans respond negatively to these environmental stressors because they affect the need for p rivacy Privacy is defined by Altman ( 1975, p. 18 ) self or Pedersen (1997) suggests a similar definition where privacy is viewed as an individual how and with whom to interact ; much akin to boundary control In a NICU setting, these would translate to shelter from unwelcomed viewin personal space According to Stewart Pollack and Menconi (2005), t he two major contributors to environmental stress are lack of control over stimuli and constant change within the environment Levels of stress vary depending on the e nvironmental stimuli such as spatial organization, movement noise and the presence of people in the setting. A greater need for environmental privacy is required for mothers of NICU infants since stress and anxiety can be higher in the NICU environment than in many other settings due to these environmental stimuli (Stew art Pollack & Menconi ). Environmental Privacy Literature on environmental privacy consists of discussion on spatial, visual and auditory privacy. Sp atial privacy or boundary control, is a category of spatial need that can be defined by Pedersen (1997) as the need to control physical access to oneself. Physical barriers, location within the unit, layout of the unit, and distance from others are all fe atures of the environment that may affect spatial privacy (Pedersen). Visual privacy also covered by Pedersen (1997) is the level of shelter that protects an individual from unwanted observation or viewing It also a llows for p ersonal autonomy which pr ovides the opportunity for self discovery and offers a chance to

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29 experiment with new behaviors without soci al condemnation Burden (1998) claimed that n ew mothers especially need visual privacy when they beg in to gain lactation skills, as t ime is needed to experiment with their bodies without judgment from others in case they fail. Literature by Stewart Pollack and Menconi (2005) on auditory privacy states that t he effect of noise, or unwanted sound, varies for each individual and is dependent on personal and environmental factors. Auditory privacy is the level of shelter that protects an individual from u nwanted sound which can interfere with concentration and the performance of tasks requiring relaxation such as lactation. Noise can also cause frustrati on or irritation, which in turn can lead to a heightened stress level in an individual (Stewart Pollack & Menconi) Personal Space Even though people are more accepting of the necessary personal space violations in a healthcare setting, it is no less traum atic than in other settings. Stewart Pollak and Menconi (2005) would even argue that personal space violation is more traumatic due to the stress and uncertainty surrounding the healthcare experience. Literature also indicates that the more intimate the sp atial relationship, the more people refuse to accept intrusion by others (Human Behavior and Interior Environment, 1997). Personal space is a term used to describe perception of social spacing. Gottlieb (1996) and Sommer (1969) illustrate this idea by desc ribing personal space as the social distance defined by an invisible concentric bubble around an individual. T hese invisible boundaries are always changing depending on the interaction needs of individual s whose ever changing needs determine both the exte nt of the bounda ries at

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30 any given time as well as their level of comfort with proximity to others (Stewart Pollack & Menconi, 2005) Altman (1975) reported that individuals with extroverted attitudes maintain closer personal space than those with introver ted attitudes and are therefore more comfortable with proximity to others. Introversion and extroversion are terms from psychology originally used by Carl Jung to explain the different attitudes people use to direct their energy. The extroverted attitude i s an outward flow of personal energy with an interest in and a dependence on events, people, things, and relationships. In addition, an extrovert can be motivated by outside factors and influenced by the environment, as well as be sociable and confident in unfamiliar surroundings 2009). Conversely, those with introverted attitude tend to be withdrawn and have an inward flow of personal energy preferring inner reflection over activity ; and are happy when alone due to their rich imagi nation The size of the personal space is further determined by density in each designated space. Density can be defined as the physical condition involving space limitations and the number of people the space contains at any point in time (Stewart Pollack & Menconi, 2005). As Aiello and Baum (1979) point out, i ncreased density can cause the inability to perform tasks, effectively interact with others cope with unpredictable situations, or attain certain goals. When density increas es, the probability that our personal space will be violated also incre ases (Stewart Pollack & Menconi ). In addition, Kaya and Feyzan (1999) and Evans and McCoy (1998) indicate that t he result of increased density is feeling a lack of control, loss of pri v acy or crowding

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31 Stewart Pollack and Menconi (2005) define crowding as a negative psychological response to overstimulation and lack of control within a densely populated environment. This includes a perceived excessive amount of interaction within a lim ited space which may be caused when privacy mechanisms fail to work (Stewart Pollack & Menconi). According to McAndrews (1993), c rowding is a condition which can be temporary or chronic. Temporary, or s hort term crowding can affect our ability to perform complex tasks, among numerous other n egative effects (McAndrews ). Chronic, or l ong term cause an increase in psychological distress (Evans, Maxwell & Hart, 1999 ; McAndr ews ). Stokols (1972) reports that i n addition to crowding, lack of privacy and restriction of movement can also contribute to a negative psychological state and feelings of encroachment. The negative effects of encroachment upon personal space includ e disl ike for the intruder, poor performance of a given task, or experience of negative emotions, such as anger, hostility, or feelings of violation (Baumeister & Bushman, 2008). Privacy Control Stewart Pollack and Menconi (2005) identified mechanisms for priva cy control includ ing nonverbal behavior and use of the physical environment. N onverbal behavior involves positioning and movement of the body to communicate with others. This is us and subtle levels ; f or example, movement toward others signals openness to communicate, while movement away from others signals avoidance (Stewart Pollack & Menconi ). Some of the most obvious nonverbal behavior humans use to communicate is directional o rientation, which can be interpreted as nonverbal communication that

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32 may signal openness to communicate or whether interaction is welcomed (Gifford & Pollack & Menconi). The usual interpretations given to these behavior signals are: 1) if an individual is facing inward from the circulation path, this indicates preference for isolation; 2) if an individual is sitting with the circulation path at his or her side, this indicates partial openness to interaction; and 3) if an individual i s facing outward toward the circulation path, this indicates openness to interaction with others. Another mechanism for privacy control is the adjustment of the physical environment. The physical environment helps us to control our personal space and inter action with others by allow ing regulation of communication and access to our bodies through manipulation of its features, such as the introduction and positioning of physical privacy devices (Stewart Pollack & Menconi ). In an observational study of the met hods women use to maintain or preserve their privacy within a maternity ward environment, Burden (1998) found curtain positioning to be the primary privacy mechanism used. This method of interaction became known as ndividual curtain to send silent messages to others in the ward environment. The degree of closure of the curtain around the if they would prefer to m aintain their isola tion (Burden ). Burden (1998) also suggested that the d ifferent stages of pregnancy and social issues contributed to the need felt by certain mothers for heightened privacy measures. Reasons that were stated for maintaining isolation, with the curtain clos ed completely around bed, were: a fear of judgment from others, to avoid others views of them in labor or breastfeeding, to avoid social contact, or because they were experiencing feelings of

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33 self doubt. This happened more often when social norms were not the same for all i ndividuals in the space (Burden ) which relates to Stewart (2005) mention of use of culturally approved behavioral norms as yet another mechanism that combines nonverbal behavior and use of the physical environment f or privacy control. According to Altimier (2004), Newell (1998), and Turnock and Kelleher (2001), all famili es desire privacy in the NICU and equate it with patient dignity. Unfortunately, the ealthcare setting is not the same consideration typically given in any other environment due to the necessary interaction with healthcare staff (Turnock & Kelleher). Stewart Pollack and Menconi (2005, p. 2) agree and add ithout the kind of control t hat the process of privacy uniquely provides, we are less able to cope with or benefit from these [healthcare] situa tions and circumstances It is generally thought that p eople resist intrusion by others as the intimacy of the spatial relationship increas es ( Human Behavior and Interior Environment 1997 ). Literature on environmental privacy is concluded by differentiat ing between desired and achieved privacy. Desired privacy can be defined as the personal feeling about the perfect level of interaction with others at any particular time whereas a chieved privacy is the actual amount of interaction individuals have with others. Stewart Pollack and Menconi (2005, p. 10) claim that t he end result of achieving the desired level of privacy is a lessened perceptio n of stress, or However, Altman (1975) and Westin (1967) state that when achieved privacy is greater than what was desired, the person is more socially isolated than was intended or

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34 wanted Conversely, when achieved privacy falls shor t of what was desired, the the person may feel crowded (Altman; Westin ). An environment where mothers have the ability to achieve desired privacy levels and are more comfortable performing activi ties such as skin to skin contact, milk expression or breastfeeding, is a necessary part of creating a restorative healing environment (Brown & Taquino, 2001; Stewart Pollack & Menconi, 2005). NICU Design The NICU is described in the literature as part of a hospital that admits newborn s in need of critical care or serious medical attention at birth. Approximately ten to 15 percent of newborns require this type of care and are admitted to a NICU where a dvanced techno logy and healthcare professionals provide these fragile infants with the specialized care they need Some NICUs also give intermediate or continuing care for less critical infants that are also in need of specialized nursing care (N eonatal Intensive Care U nit, 2009) Cooper et al. (2007) reported t he unfamiliar environment of a NICU to be quite overwhelming for a parent thus c onsideration must be paid in designing a NICU that supports families caring for their infant. The physical characteri stics should complement the care provided by the family and should offer relief instead of contribut ing to the overwhelming nature of the experience (Cooper et al.) Johnson et al. (2004, p. 1) agree that t he physical features of a NICU and its approach to care go The Recommended Standards for Newborn ICU Design is a set of guidelines that provide the professionals involved in the planning of NICUs with a comprehensive set of design standards based on clinical experience and an evolving sc ientific database

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35 (Marshall Baker, 2006; White, 2007 b ). S tandards listed in these guidelines are minimum recommendations, not codes or standards required by law T heir intent is to optimize design within the constraints of available resources and facilitat e health care for the infant in a setting that supports the role of the family and the needs of the staff members (White ). One of the twenty seven standards from the list of Recommended Standards pertains especially to the study of environmental privacy in an open bay NICU. Standard 3 considers minimum space, clearances and privacy requirements and specifically states: Each infant space shall contain a minimum of 120 sq ft of clear floor space, excluding hand washing stations, columns and aisles. There sha ll be an aisle adjacent to each infant space with a minimum width of 4 ft in multiple bed rooms. Multiple bed rooms shall have a minimum of 8 ft (2.4 m) between infant beds. There shall be provision for visual privacy for each bed. (White, 2007 b p. S7 ) Th ese guidelines imply that b edside area should provide enough space for parenting and family involvement as well as interaction of the healthcare staff with the infant Furthermore, permanent objects such as hand washing stations or columns should not infr inge upon the bedside space or overlap adjacent areas s uch as circulation, as circulation has its own spatial requirements. The guidelines also imply that visual privacy for the family should be addressed both at each bedside, as well as in the overall uni t design (White 2007 b ) A second standard from the list of Recommended Standards is relevant to the environmental in an open bay NICU Standard 7 describes clearances for h andwashing s tations and specifically sugge sts:

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36 In a multiple bed room, every infant bed shall be within 20 feet (6 meters) of a hands free handwashing station. Handwashing stations shall be no closer than 3 feet (0.9 meter) from an infant bed or clean supply storage (White, 2007 b p. S8 This gui deline implies that a handwashing station should be close enough to infant bedsides to be convenient for use by staff or family, yet there should exist enough distance from the nearest bedside so as to not cause a disturbance. The handwashing station shoul d also provide ease of operation and consider noise control (White, 2007b). Shepley et al. (2008) explored the design implications of s ingle family room ( SFR ) NICUs relative to open bay arrangements and the caregiver experience. From staff viewpoints, SFR s support privacy for famili es and infants better than open bay units. Staff also agrees that SFRs are viewed to be le ss stressful for family members, as SFRs provide family members with sleeping and waiting areas. Factors that raise stress levels, such as unwelco med viewing of oneself or child and intrusion of excessive noise, are mitigated in the SFR in comparison to open bay unit options (Shepley et al. ). According to Stewart Pollack and Menconi (2005), t he challenge for open bay NICUs, where families mu st share space, is to provide as much control and individual privacy wi thin the limited space as the SFR units However, literature on the disadvantages of the SFR design from Domanico et al. (2010) and White (2003) reports gical advances in patient monitoring, nurses generally feel more confident about the condition of their patients if they can physically see them at all times. White also indicates that SFRs configurations tend to isolate nurses from one another, as nurses are used to working as a team, even if they are given individual assignments. It is easier for nurses to

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37 collaborate and socialize in an open bay unit, which is not afforded to them in a NICU where most of the beds are in individual rooms (White) In addi tion, Domanico et al. ( 2010 ) and White ( 2003 ) s uggest that this issue of isolation is a factor for parents as well as nurses Inter parental socialization was difficult in SFR configurations due to the relative isolation of parents. Domanico et al. also fo und that the open unit outperformed the SFR regarding the ease of meeting other parents and providing parental support to make the hospital stay better ( Domanico et al. ) White reported another disadvantage to SFR design is the cost. Individual rooms are m ore expensive due to their larger space consumption. Even if the beds were afforded the same square footage in each type of unit, the space required for individual rooms is greater due to the existence of more walls, which consume space and limit circulati on and flexibility ( White ) Conclusion Many studies have been conducted about perceived stress levels of parents and other caretakers in the neonatal intensive care unit. F to environmental privacy during the lactation proc ess in an open bay unit. Specifically, little is known about stress created by the lack of environmental privacy during milk expression and breastfeeding processes It is necessary to clarify the impact environmental privacy has on

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38 CHAPTER 3 RESEARCH METHODOLOGY The research objective s of this study were to determine whether a perceived control of her environmental privacy conditions experience in an ope n bay neonatal intensive care unit (NICU) and whether the extent of environmental privacy affects the perceived stress level of mothers who are expressing milk or breastfeeding Based on the findings as well as previous empirical work, t he study also proposes recommendations for privacy design techniques to benefit NICU designers and staff. Research Study Design A case study method was utilized in this study. This design approach provided information to understand maternal behavi physical environment had on lactation and stress. The ability to utilize a variety of evidence is the unique strength of the case study design and justifies its selection for this application. The study relied on observations, interviews, and questionnaires to preferences for privacy, as well as perceptions of stress. case design was chosen to represent the e xperience for a mother whose infant has been admitted to a NICU and who is carrying out lactation The lessons learned from this study are assumed to reveal the experiences of an average woman in these circumstances Non p articipant o bservations were s elected for use in this situation to r ecord each behavior, as well as their interaction s with the physical environment of the NICU These observation s were utilized to provide conclusions about the mother s

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39 function s in the open bay unit (Kumar, 2005) In addition, t he process of architectural analysis was employed to define the architectural characteristics of the physical environment (Architectural Analysis, 2011) Floor plans were examined and information was derive d to bedside space utilization. The interview was a critical source of information in this case study since it focus ed on the human behavioral events. Ea ch interview became a guided conversation rather than a structured set of qu estions and the d eliver y of questions was friendly and nonthreatening in nature The interview s for this study could be considered focused interview s as the participants were interviewed for a shorter period of time and followed a set of predetermined que stions ( Gerring, 2007; Yin, 200 9 ) The case study method also allowed for more structured and targeted questions, in the form of a questionnaire. The questionnaire produced small amounts of quantitative data from the parental stressor rating scale and dem ographic information as part of the case study evidence. Theoretical Framework A review of the literature established that the hospitalization of a newborn is an inherently stressful, difficult and emotional experience for parents; and that parent child in teraction, such as lactation and skin to skin contact, are beneficial to both mothers and infants. As revealed by the literature, many factors could affect the parent child interaction time in an open s level. The most singular of these is provides the theoretical anchor for this study. demands that approach or exceed the limits of th eir coping resources (see Figure 3 1 ).

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40 framework was selected with the premise that mothers need control to alleviate stress and need privacy to have peace of mind. M others in the NICU suffer stress partly due to their environmental conditions, which consequently affects their parenting and capacity to interact with their child (Magnusson). Figure 3 1 Application of this theory established that Subsequently, a theoretical model was informed by this theory and resulted in the determination of factors that influence the lact factors include social cultural and environmental factors (see Figure 3 2 ). Altman regulation process in which a person or a group sometimes wants to b e separated from others and According to Altman, different types of social units can be involved in privacy; for instance, individuals, families, or other groups. Therefore, privacy involve s a diversity of soc ial relationships, such as individuals and individuals, individuals and groups, groups and individuals, etc.

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41 (Altman). Altman also points out that all cultures have behavioral methods for managing accessibility of people to others. The difference between c ultures is how they achieve control over interaction (Altman) Finally, Altman views environmental design for privacy as the creation of physical environments that permit differing degrees of controllability over interaction with others. Figure 3 2 Fa ctors i nfluencing l actating m p rivacy This study focuses specifically on existing environmental factors in an open bay bedside and may lead to additional stress An environmental factor can be thought of as an identifiable element in the physical environment that affects behavioral operations while in a particular setting. In the case of an open bay NICU, the environmental elements that affect the privacy of moth ers while lactating include density and sense of control. Density is a spatial condition which involves space limitations and the number of people within that space ( Altman, 1975; Stewart Pollack & Menconi, 2005). Increased density can cause the inability for a mother to perform lactation, effectively interact with

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42 her infant, or cope with an unpredicted situation. Sense of control, on the other hand, is a perceived relationship between an individual and their environment ( Altman; Stewart Pollack & Menconi) may be imperv ious to environmental stressors. Setting The site of this research study was two open bay NICUs, both residing at Shands Hospital at the University of Florida. Shands is a privat e, not for profit university hospital that specializes in tertiary care for critically ill patients and is dedicated to patient care, provide intensive care for infants ar ound the region (Neonatal Care, 2011). Founded in 1963, the first of the two NICUs is the Level III NICU, which was renovated and expanded in January 2005. At that time, the space was increased to include capacity for 22 bed s and has since boasted a 97% oc cupancy rate (Overview, 2009). A Level III NICU, or subspecialty NICU, is a special care nursery organized with continuously available staff and equipment which are able to provide constant life support and comprehensive care for extremely high risk infant s or those with complex or serious illnesses. The ability to provide care to infants with differing degrees of complexity and risk is what distinguishes the Level III NICU from other levels of care (Levels of Neonatal Care, 2011). Adjacent to the NICU III the Level II NICU has the ability to accommodate up to 30 beds and has a 96% occupancy rate (Overview, 2009). A Level II, or specialty NICU, is a NICU with personnel and equipment that are able to provide care to infants who are moderately ill, but that are expected to improve at a fairly rapid pace. These newborn

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43 more than 1500 g rams at birth. A number of infants in this NICU are patients recovering from an illness that w as originally treated in the Level III NICU (Levels of Neonatal Care, 2011). The unit is staffed by board certified neonatologists and pediatric surgeons, neonatal nurse practitioners and physician assistants, as well as nurses, respiratory therapists, t ransport specialists and other specially trained support staff. All of these caregivers are on hand around the clock to respond to newborn infants in need of highly skilled care. The team also prepares each family for life at home with essential training i n infant care, cardiopulmonary r esuscitation ( CPR ) and appropriate follow up (Neonatal Care, 2011). Layout. The two NICUs, although separated from each other by two short hallways, each have a floor plan organized as an open bay unit, meaning neither one c ontain general patient areas that are physically separated from one another by solid walls. Even though they have the commonality of the open plan, the units have very different configurations. The Level III unit contains two four bed pods in the central s pace of the linear unit, with an additional 14 beds located around the perimeter (see Figure 3 3 ). Two of the perimeter beds were enclosed so that privacy could be controlled for surgical or other special procedures. T wo additional perimeter beds were semi enclosed by glass walls Station is located adjacent to these four special rooms, yet still provid es accessibility and support to the rest of the unit.

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44 The Level II I NICU incorporate s other design features that differ from NICU II C urved and angled lines in NICU III create fluid directionality within the unit A curved wall is prominently located at the visitor entrance to the unit which has a softened e ffect when e ntering the space It is complemented b y other walls, furniture and applied dcor that have curved or eased forms which contribute to the perception of a calm environment by creating relief from sharp edges that may harm or suggest harm Conversely, t he furniture and equipment in the Level II NICU are set up in a linear fashion in three rows that run parallel from one end of the room to the other, with equipment storage acting as a barrier to separate two o f the three rows (see Figure 3 4 ). None of the pa tient spaces can be enclosed in this unit to provide special procedures or to grant privacy from others, and the infant beds are situated closer to easily viewed by anyone standing in the unit. Unlike the Level III NICU, the Level II NICU features only recti linear forms Limited space exists in each NICU for families to visit, including mothers, fathers, and extended family members. Families spend many hours in the restric ted space infant. Only one private room in the unit is available for an overnight stay, which is located in the Level II unit, and is utilized by the parents of both uni ts. Another private room is available in the Level II unit for other personal activities, and is sometimes used as an overnight room for parents to stay when occupancy is at capacity. Although extended family is allowed into the unit during visiting hours, there is also a large waiting

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45 room adjacent to both NICUs that can accommodate visitor overflow In addition, a milk expression room is offered to those mothers w ho desire to lactate in private Color and light. Further differences between the two units c an be found in the coloration and materiality of the spaces The Level III NICU features a calming gray, white and blue color scheme on the walls and surfaces with hints of other pastel colors as accents. The Level II design is comprised of white walls and surfaces, but has incorporated a flooring material that simulates wood. By using a material that evokes nature, this feature creates a warming effect in the space as opposed to the gray and white marbleized flooring in the Level III NICU. One more key di fference between the two spaces is the amount of natural light permitted into the unit. Level III allows ample amounts of light from windows in one of the longer walls which allows natural light to enter into the space, while the Level II unit has only six small windows to let the light in. Due to the critical state of the infants whose exposure to light may not always be desirable all of the windows feature operable shading measures.

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46 Figure 3 3 Level III NICU f loor p lan (not to scale) Figure 3 4 Level II NICU f loor p lan (not to scale) Seating. is the same in each unit. The mothers have the option of selecting a pink or blue upholstered recliner

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47 chair that is vinyl covered and on lockable casters, a rocking chair made entirely of wood with a contoured seat, or an upholstered office chair with arms and casters (see Figure 3 5 ) There is a limited amount of each type available in the units, so options are contingent on how many chairs are alr eady being used at the time of selection. The office chairs were originally placed in the unit for staff to use at the satellite computers s but have been made available to the mothers if they desire them. A nursing stool is also availa ble for mothers who are nursing (see Figure 3 5 ) A B C D Figure 3 5 Furniture e xample s similar to those found in both NICUs A) r ecliner chair ( www. swmedsource.com) B) r ocking chair ( www. simplybabyfurniture.com) C) o ffice chair ( www. steel case.com) and D) n ursing stool ( www. medelabreastfeeding us.com)

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48 Study Instruments circumstances, as well as the Health Insurance Portability and Accountability Act of 1996 ( HIPAA) which limits the type of information that can be accessed or referenced for external examination, data was collected through suitable methods such as observation, interview, and questionnaire. The collected information provided evidence of each part environment of the NICU. Interview. The focused interview instrument was prepared to be conversat ional in nature with 14 open ended questions to guide the interview er These question s inquired comfort provided to them aid of NICU sta ff, and whether desired privacy was achieved A recording device was used during each interview to provide a more accurate account of the conversation. Questionnaire. A 54 question structured questionnaire instrument was created for each participant to sel f report stressors occurring in the physical and psychosocial environment of the NICU. First, the questionnaire asked mothers about the time spent visiting their child and her activities while visiting in the NICU. Next, the questionnaire utilized the Pare ntal Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU), an instrument developed by Miles, Funk and Carlson (1993) to measure the parental perception of stress in the NICU environment. Finally, the questionnaire collected demographic information.

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49 The PSS:NICU instrument asked the participants to rate the stressfulness of their experiences on a scale of 1 to 5 in three categories The three dimensions of the PSS:NICU are: Sights and Sounds of the Unit, Infant Behavior and Appearance, and Parental Role Alteration (Miles et al. 1993). The rating scale can be d efined as follows: 1 or or or or or had the option to select an experience. Pilot Study. Before the final data collection occurred, a pilot study was conducted to refine the collection strategy with respect to both the content of the data and the procedures to be followed. Three p articipants were approached to participate in this segment of the study. The first participant was chosen out of convenience to the researcher bay NICU environment. This participant utilized a retrospective view at the time of interview. The other two participants were selected from the current population within the NICU environment that was later to be used for the final case study. One of these two participants was located in the open space of NICU II, the other was located in a surgical room within NICU III and was utilizing a retrospective account as she had previously spent time in the open space of the Level III NICU. As a result of this pilot test, there were minor changes to the process and instrument prior to the final study. It was first determined that no retrospective accounts should be made as these reports were not as reliable as the account made by the able to be observed in a retrospective account. Secondly, it was decided that the

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50 this time allotment was judged to be enough time spent in the unit to have experienced most of the behaviors bei ng studied. This time allotment had also been used for previous studies by others ( Burden, 1998 ; Carter, Carter & Bennett, 2008 ; Fontes Pinto Novaes, Knobel, Bork, Pav o, Nogueir a Martins & Bosi Ferraz, 1999 ). Third, the interview questions were reordere d to provide a better flow of conversation. Finally, it was decided that mothers who were not yet successful at expressing milk or breastfeeding would also be asked to participate, instead of only approaching mothers who were currently breastfeeding. This could possibly determine whether the unit configuration, in regards to privacy, had any influence on the success rate of lactation. Observation Field notes and measurements were taken during data collection to create behavioral maps that chart the individ ual locations within the NICU space (see Figure 3 6 ). The information gathered was used to illustrate the possible factors that affected their perceived privacy (Somme r & Sommer, 2002 )

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51 A B Figure 3 6 Behavioral m aps with location of each participant A ) NICU III and B ) NICU II.

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52 Sampling Procedure For this study, a non probability sampling design known as quota sampling was utilized (Kumar, 2005). Following t his model, the sample was selected from participants located within the NICU environment. Whenever a person with relevant characteristics was available and willing, that person was asked to participate in the study To obtain these study participants, a N eonatal Nurse Practitioner currently working in the NICU screened for possible participants by privately asking each potential participant about involvement in the study prior to introduction to the principal researcher. This meant that identifiable inform ation was not shared with the researcher and no connection can be made between the collected data and participants of the the NICU more than 24 hours prior; 2) partic ipants infants were located in one of the open bay infant beds, which excluded the closed surgical rooms; 3) most, but not all of the participants should be expressing milk or lactating prior to participating in this study. A participant who was not expre ssing milk or breastfeeding at the time of study was included to find out if the NICU environment was keeping her from establishing lactation Data Collection Informed C onsent Participants were presented with an informed consent form to obtain written c onsent to complete the study. The study posed no risks to participants and they could withdraw at any time. The participant was given the opportunity to consider all options and ask questions about the process. Their signature was required for control purp oses;

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53 copy of the informed consent document was released to the participant for their reference. Questionnaire Participants were next asked to fill out the four page quest ionnaire about their had any questions about the instrument. Notes and observations about the individual filling in questionnaire answers. Included in these notes were: date and time; location of participant within the NICU; how much family surrounded the mother; extra information provided to the researcher by the participant upon first meeting; source of au ditory noise; lighting source and availability of additional lighting, approximate density; whether staff was attending to their infant; furniture used by mother; space being utilized by personal belongings; and if they were presently breastfeeding at the time of interview. Interview Following the questionnaire, participants were asked if they were willing to participate in an interview to provide further information about their environmental privacy experiences in the NICU. All but one participant obliged The interview consisted of a series of open ended questions where the participant was encouraged to say as little or as much as they would like. Most were willing to engage in thoughtful conversation. These interviews lasted between 15 to 45 minutes, dep ending on the A small gift was presented to each participant upon completion of all data collection researcher of their expe riences while in the NICU environment.

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54 This process continued until sufficient data was collected; the total study lasted approximately eight weeks. During this time, the census of these combined NICUs was low, with an average 36 of 52 beds filled at the time of data collection. Sample The participant group in this study consisted of 20 mothers who had at least open bay NICUs (n=20). Fourteen participants were obtained f rom the Level II NICU and six from NICU III. All participants were American citizens originally from either the 50 states or overseas territories This group included females whose ages ranged from 19 to 39 years of age, with the average age of the partic ipants being 29.7 years. All of the age ranges were well represented with the most frequent age range being between the ages of 31 35 years old as seen in Table 3 1. Table 3 1. Participant a ge ( n =20) Age in Years Number (%) 18 20 2 10 21 25 3 15 26 30 5 25 31 35 7 35 36 40 3 15 Table 3 2 reveals that just over half of these female study participants are currently married, with a quarter of the participants being single or never married. Only three mothers were divorced or separated, and none of the participants were widowed The majority of participants attended at least some college (see Table 3 3) which could completed college or held a professional degree.

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55 More than half of the participants declared they were employed, as seen in Table 3 employment position of Teacher or Professor (n=4) O ther employment positions include d Nationa l Sales Assistant, Family Liaison Specialist, Accountant, Cashier, Insurance Instructor, Licensed Practical Nurse (LPN ) and Pharmacist. Additionally, t he most common range of combined family income was less than $20,000 per year (see Table 3 5) Table 3 3. Years of s chool c ompleted ( n =20) Education Number (%) Attended Some High School 2 10 High School Graduate 2 10 Attended Some College 8 40 College Graduate 5 25 Hold a Graduate or Professional Degree 3 15 Table 3 4. Employment ( n =20) Employment Number (%) Were Employed 11 55 Were Not Employed 9 45 Table 3 5. Combined f amily i ncome ( n =20) Income N umber (%) Less than $20,000 6 30 $20,00 0 $40,000 3 15 $40,00 1 $60,000 4 20 $60,00 1 $80,000 2 10 $80,00 1 $100,000 3 15 More than $100,000 0 0 Chose Not to Answer 2 10 Table 3 2. Marital s tatus ( n =20) Status Number (%) Married 11 55 Single/Never Married 5 25 Divorced/Separated 3 15 Widowed 0 0 Chose Not to Answer 1 5

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56 Data Analysis The data collected in thi s study is generally qualitative, which is defined by a flexible method that explores the nature of the problem while capturing the richness and diversity of each experience ( Kumar, 2005; Sommer & Sommer, 2002 ). The data was obtained through observations, interviews and questionnaires, which were then analyzed A simple content analysis was used to analyze the participant interview responses to see what themes emerged and how they related to each other First, an utterance analysis was perf ormed which found the frequency at which a topic was mentioned. Steps in this process included transcribing the interviews performing topical analyses of the content identifying primary and secondary categories, performing a frequency count o n the differ ent categories, quantifying frequencies, and calculating percentages and averages. Second, an interview analysis by respondent was performed to summarize the interview responses. The responses and main themes that emerged were then integrated into the find ings chapter. Alternately the PSS:NICU data was analyzed by quantitative methods. Since the focus was on the NICU environment, Miles et al. (19 9 3) recommended using Metric 1, or the Stress Occurrence Level system for scoring the results For thi s type of scor ing only those participants who reported having the experience provided a score for each item. Others who did not have the experience were coded as missing. An average score was then calculated for each item which included all participants w ho experienced that stressor (Miles et al. ) These results allowed the data from the stressor scale to be ranked from the most to the least stressful NICU experience

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57 Limitations Limitations of this study include the use of an available NICU with its exis ting environmental features, the research performed at only one site, the available number of participants at time of data collection, and the maturation of its participants. Also, the University of Florida Institutional Review Board (IRB) rules about the Health Insurance Portability and Accountab ility Act of 1996 (HIPAA) were followed, which limited the kind of information that could be accessed, referenced or used in this study. A few examples of the i nformation not used due to IRB and HIPAA regulations w ith respect to behavioral research include d the birth weight of the newborn and the condition or treatment Assumptions It was assumed that even though the layout design of the two NICUs were different, findings will be similar since each environment utilizes the same staff, privacy mechanisms and furniture. It was also assumed that even though each mother is afforded the same privacy mechanisms, introverted mothers would have a more difficult experience in an open bay NI CU due to their preference for inner reflection over activity and comfort with solitude.

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58 CHAPTER 4 FINDINGS This chapter presents the results of data collected from the combined neonatal intensive care units ( NICUs ) as described in the previous chapte r. The characteristics of p articipant s lactation, stress, environmental privacy and unit design were observed and analyzed. The impact these factors had on the participant experience is described below Mother s Twenty participants agreed to ta ke part in the written questionnaire portion of the study. In addition, 19 mothers agreed to participate in the verbal interview and made observations which contributed to the body of findings. As revealed by the results of the questionnaire, a ll mothers participating in this study (100% n=20 ) reported spending most, and sometimes all of their time at the 15 percent (n=3) included spending time in the milk expression room and five percent (n=1) re ported spending varied due to their date of admittance to the NICU. Nonetheless, the average number of days the participant s reported that their infant had spent in the NICU was revealed by the questionnaire results to be 23.9 days. The longest length reported was 77 days, and the shortest length was only two days. The amount o f time each participant spent visiting their infan t in the NICU varied as well. Visiting hours were limited to a twelve hour period, from 9 a.m. to 9 p.m., seven days a week (Visiting Hours, 2006) In addition, there was little to no space for each

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59 mother to stay overnight near her infant. The questionnai re results indicated that t he to be relative, with the average length of visit per day being 7.4 hours. Table 4 1 illustrates that the majority of mothers either visited their infant for less than four hours (40% n =8 ) or more than nine hours (40% n=8 ). The remaining 20 percent (n=4) spen t between five and eight hours with their infant per day. Table 4 1 Average length of t ime participants s pent in the NICU per d ay ( n =20) Hours Number (%) 0 4 .0 8 40 4 .1 8 .0 4 2 0 8 .1 12+ 8 40 Lactation The NICU spaces were found to support the active engagement of parents in the care of their infant, which is the basis of family centered care. The NICU and its staff support breastfeeding, skin to skin contact, and developmenta l care. Lactation a bility The majority of participants (95%, n=19), revealed by the questionnaire, were able to lactate at time of study. The one participant who reported inability to lactate had been admitted to the unit just two days prior and had attemp ted to breastfeed, but at the time of participation had not yet been s uccessful. One respondent even mentioned that the hospital offers a lactation specialist if a mother is having trouble lactating. The questionnaire also indicated that 75 percent of part icipants (n=15) were (n=12) were successful at breastfeeding at bedside (see Table 4 2 ). Even though the success rate for breastfeeding was lower than for expressing milk, 75 percent of the participant

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60 population (n=15) reported the ability to make skin to skin contact with their infant right before beginning a lactation session. Table 4 2 Success of e xpressing m ilk or b reastfeeding at edside ( n =20) Expressin g Milk Breastfeeding Number (%) Number (%) Successful 15 75 12 60 Attempted, Not Successful 1 5 5 25 Had Not Attempted 4 20 3 15 Distraction Content analysis by respondent established the primary environmental distraction which kept mothers from initiating lactation while in the NICU was the noise level; including crying infants and monitor alarms (27%, n=5). Secondary distractions included movement, people or busyness around the participant (11%, n=2), lack of visual privacy (6% n=1), or environmental privacy, in general (6%, n=1). Surprisingly, the majority of participants (50%, n=9) found no environmental distractions keeping them from initiating lactation. Even though 50 percent (n=9) of respondents suggested they were not affected by distractions in the environment, other non environmental distractions were noted that kept participants from initiating lactation. These disturbances included trouble with the baby latching on (6%, n=1); finances or other internal thoughts (6% n=1); difficulty positioning the baby for breastfeeding (6%, n=1) or providing enough milk for twins (6%, lines for necessary medical equipment getting in the way of lactation (6%, n=1).

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61 Maternal Stress Previous e xperience According to the results of the questionnaire, this experience was found to be the first child rearing experience for 50 percent of the participants (n=10) Even though the remaining 50 percent of re spondents reported having other children, 20 percent of the m (n=2) had not previously breastfed or expressed milk. Therefore, a total of 60 percent of all participants in the study (n=12) did not possess previous lactation experience (see Figure 4 1) A B Figure 4 1 Participants with previous experience. A ) W ith o ther c hildren B ) With lactation experience. In this study, having another child or previous lactation experience were found to not be factors in determining whether the participant was more or less stressed. Experienced mothers reported overall stress levels similarly to inexperienced mothers. By cross referencing questionnaire data regarding previous experience to overall Parental Stressor Scale: Neonatal Intensive Care Unit ( PSS: NICU ) score s it was revealed that each participant who answered this question (n=17) claimed the experience of having their baby hospitalized in the NICU was between a score of 3 and 5 or from moderately to extremely stressful (see Table 4 3 ) with a med ian score of 3.71

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62 Table 4 3 Previous child rearing and lactation experience and how each relates to overall stressfulness of the NICU environment ( n =17) Rating 1 2 3 4 5 Child experience frequency No other children 0 0 5 3 2 W ith other children 0 0 3 3 1 Lactation frequency No lactation experience 0 0 6 3 2 W ith lactation experience 0 0 2 3 1 a) Self reported general stressfulness of NICU experience on a scale of 1 to 5. Internal p sychology M others in this study were asked whether they considered themselves introverts or extroverts. Questionnaire findings revealed that 60 percent of the participants (n=12) reported that their internal psychology was introverted (see Figure 4 2). Thirty five pe rcent of respondents (n=7) described their personality as extroverted and one participant chose not to answer this question. Figure 4 2 Extroverted versus i ntroverted internal psychology. The study found that self assessed introverts reported higher ra tings of stress more times than extroverts. Of the participant population that considers themselves an introvert (n=12) all combined PSS:NICU stressor scores fell between the ratings of 2 to 5 -a little stressful to extremely stressful -with a median score of 3.24 In contrast, the (n=7) fell between 1 and 4 -not at all stressful to very stressful -with a median score of 2.93 (see Figure 4 3 ).

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63 Figure 4 3 Overall stress l evel r ating of introverts and ex troverts. N eonatal intensive care unit experiences The PSS:NICU, which was embedded in the participant questionnaire, required participants to rate stressors in three categories: Sights and Sounds, Baby Looks and Behaves/Treatments, and Relationship with B aby/Parental Role Table 4 4 illustrates the average rating given by participants to the experiences in each category, and the number of participants who experienced it. If a participant did not have the experience in the NICU environment, they were not in cluded in the frequency count.

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64 Table 4 4 A verage rating of stressors and frequency of participant experience from the PSS:NICU (n =20) Stressor Average Rating n Sights and Sounds Having a machine breathe for baby 3.33 9 S udden monitor alar m noise 2.95 20 Constant monitor and equipment noise 2.55 20 M onitor s and equipment presence 2.35 20 Other sick babies in the room 2.22 18 Large number of staff in the unit 1.90 20 Baby Looks and Behaves/Treatments Baby seemed to be in pain 4.21 19 Baby looked sad 3.67 15 Needles and tubes put in baby 3.50 18 Unusual or abnormal breathing patterns 3.36 14 Limp and weak appearance of baby 3.36 11 Tubes/equipment on or near baby 3.05 20 Bruises, cuts, incisions on baby 3.00 15 Unu sual color of baby 3.00 12 Baby looked afraid 3.00 8 Small size of baby 2.93 15 Baby fed by intravenous line or tube 2.56 16 Jerky or restless movements of baby 2.44 18 Wrinkled appearance of baby 1.23 13 Relationship with Baby /P arental Role Being separated from baby 4.58 20 Not being able to hold baby when I want 4.19 16 Feeling helpless and unable to protect baby from pain 4.11 19 Feeling helpless about how to help baby during this time 3.94 18 Not having time to be alone with bab y 3.41 18 Not being able to care for baby myself 3.41 17 Not feeding baby myself 3.37 20 Inability to share baby with family members 3.08 13 Being afraid of touching or holding baby 2.23 13 Overall Rating General stress rating of having baby h ospitalized in the NICU 3.71 17

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65 rated the most stressful experience, with an average rating of 3.33 on a scale of 1 to 5, with nine of the 20 participants experiencing this str ess indicator. The second most stressful item, which the entire maternal participant population experienced (n=20), was corresponds with the content analysis results by res pondent which found noise levels in the NICU to be the biggest distraction that kept mothers from initiating lactation. Findings indicate that 54 percent of those who were distracted during lactation were agitated by noise The environmental questions wi thin the Sights and Sounds section of the PSS:NICU asked for participants to rate the presence of equipment, noise, other sick infants, and staff nearby. The participants who gave the highest ratings in this category were the subjects located near key inte rsections in each NICU environment (see Figure 4 4 ). A

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66 B Figure 4 4 Behavioral map of Sights and Sounds category scores. A ) NICU III and B) NICU II. In the Baby Looks and Behaves/Treatments category from the PSS:NICU the most stressful experience 4.21 on the 5 point scale. The experience in the Relationship with Baby/Parental Role category that was rated mo had an average rating of 4.58 and was experienced by all mothers participating in this study. These factor s though extremely significant, escape the scope of this study. When the PSS:NICU scores were tallied per stressor, the environmental privacy experiences were located toward the bottom half of the list (see Figure 4 5 ). These experiences were not found to be as highly stressful to mothers in the NICU environment. The experience that was ranke d as the h ighest stressor among being separated from my baby wrinkled appearan In addition, 79 percent of the

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67 PSS:NICU items were rated above the halfway point of the 1 to 5 ratin gs, meaning that only 21 percent of experiences were in the range from zero to 2.5; the median score of the 28 stressors was 3.10. Figure 4 5 Order of stressors by average PSS:NICU score per experience ( n =20).

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68 Environmental Privacy Environmental Stres sors In order to determine which environmental stressors in the open bay unit design n utterance analysis of the interview s was performed. The results of the analysis uncovered the participant frequent references to the environmental stressors (see Figure 4 6 ) The utterance analysis also revealed which references were most frequent concerning coping with these stressors (see Figure 4 9 ). Utterance analysis of mother interviews suggest s that environmental stressors in the NICU could be grouped into three categories: Environmental Features Furniture and Family Intrusion Out of 113 utterances the Environmental Features category, consisting of references to lighting influence, noise in trusion and spatial layout, appeared to be the most frequently referred to, with 49 percent of utterance s (n=55). The next highest cited category was Furniture, which claimed 34 percent of utterances (n=39) and contained comments about seating and storage bedside. The third highest cited category regarding environmental stressors was Family Intrusion, which amassed 17 percent of the utterance s (n=19), and indicated that other family members in the unit contributed as stressors to the participants.

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69 Category Sub Category Code Freq. % Unit Design Environmental Features Features that exist in the unit that may or may not contribute to stress (LTG + NSE + SLO) EVF 55 49 Lighting Influence Lighting sources which a ffect mother or infant in the unit LTG 6 Noise Intrusion Noise in the unit; generally negative sound intrusion NSE 14 Spatial Layout Reference to the space being open (generally negative); room configuration; distance from others; personal sp ace ; or private rooms SLO 35 Furniture Moveable or stationary articles for comfort at bedside (STG + SRG) FUR 39 34 Seating Seating options for use during lactation at bedside STG 24 Storage Location of personal belongings; cabinetry (draw er, counter top), floor, bassinet SRG 15 People Family Intrusion Reference to the participants' family or other infants' families affecting the mother's experience FMI 19 17 Figure 4 6 Content analysis of participant utterances regarding environment al stressors ( n =113) The unit design Recommended standards. The physical environment of the open bay NICU was evaluated by means of an architectural analysis. Space utilization of the NICU was assessed by comparing the current environment to the guidelines listed in the Recommended Standards for the Newborn ICU Design. However, t he Recommended Standards were overhauled in 2006, a full year after the NICU renovation and

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70 Findings from the architectural analysis reveal ed that each NICU met minimum suggested aisle clearance adjacent to each infant bed even though the minimum clearance was increased to eight feet between infant beds in 2006 Similarly, v isual privacy provisions were met although there were n o fixed screening devices at the bedside P lenty of visual privacy provisions were available however including the use of portable screens, nursing covers, blankets, and the milk expression room. NICU III met and exceeded the recommended space allotment f or bedside from Standard 3 however, the bedsides in NICU II failed to meet the minimum square footage requirement. Similarly, NICU III is compliant with the guideline for minimum clearance ds, but with an Another guideline, Standard 7: Handwashing Stations, was revised in 2006 to recommend that infant beds were to be located no closer than 3 feet to a handwashing station. The results of the archi tectural analysis indicated that neither NICU completely accommodates the distances specified by this standard. NICU III met the minimum 3 foot clearance between the handwashing stations and infant beds, yet failed to meet the maximum distance from the sta tions to every bed in the unit. Conversely, NICU II met the maximum 20 foot distance from each infant bed to at least one handwashing station, but just missed complying with the 3 foot minimum due to the addition of a temporary infant bed located within 3 feet of a handwashing sink. Furniture for s torage Utterance analysis of participant interviews indicated that out of the 39 utterances related to furniture in the NICU design, 38 percent (n=15) made belongings. Results of the content

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71 analysis by respondent established storage strategies at each bedside space to include top which was also used by NICU staff, or the f respondents in NICU II expressed worry about her belongings being in the nursing cubby or dedicated space for her possessions. A second participant in the same unit thought of her belongings as a tripping hazard on the floor, with another participant mentioning her aversion to her things being on the floor since she was unsure of its cleanliness. A third respondent made note that sh e would prefer not to have to transport her belongings back and forth from home each day; and would like to see some sort of long term storage for parents. Lockable storage did exist, however, near the NICU III entry for families currently visiting the inf ant. Seating for l actation According to utterance analysis results of the interviews, 62 percent (n=24) of the 39 comments about furniture in unit design were related to seating analysis by respondent established that 59 percent of participants (n=10) found the furniture at their Alternately, 41 percent of participants (n=7) thought the furniture did not provide adequate comfort during lactation, yet there was not a clear preference for type of seating by mother. Respondent analysis found that 47 percent of participants (n=8) favored the cushioned recliner chair, 23 percent (n=4) had only used the rocking chair and found it uncomfortable, 18 percent (n=3) liked both the wooden rocking chair and

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72 cushioned recliner ch air, 6 percent (n=1) preferred the wooden rocker, but not the cushioned recliner, and 6 percent of participants (n=1) did not like eithe r chair. Spatial o rientation and c irculation Measurements of each NICU space were recorded and notes of participant behavior patterns and locations were documented via behavioral map s. Mapping the the var iation in positing toward the infant which was exhibited by mothers. The spatial orientation, or nonverbal behavior, of each participant was observed by the researcher. The majority of the mothers (65%, n=11 ) faced inward from the circulation path while 2 5 percent ( n=5 ) directly faced their including one mother who was standing instead of sitting The final ten percent of participants (n=2) faced outward toward the circulation path as seen in Figure 4 7 A

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73 B Figure 4 7 Behavioral maps illustrating ) NICU III and B ) NICU II. Relationship of the bedside space with respect to the circulation path is also illustrated by a behavioral map. Mapping of th is relationship is important in determining the amount of movement or incidental interaction exists in the unit. Infant bedsides that are located directly adjacent to the circulation path garner the least amount of spatial or visual privacy. Figure 4 8 ill ustrates the primary and secondary circulation paths of the visitors, as well as the circulation path of the NICU staff.

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74 A B Figure 4 8 Behavioral map of visitor and staff circulation. A) NICU III and B ) NICU II. Coping with Environmental Stres sors Another group of participant utterance s were related to coping with environmental stressors. Results of utterance analysis indicated that coping strategies could be categorized as Control of Environmental Features and Staff Accommodation (see

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75 Figure 4 9 ) Out of 152 utterances, the most significant category of reference was related to Control of Environmental Features, or lighting, noise and spatial controllability, with 78 percent (n=118) of utterances. Spatial controllability, a sub group of Contro l of Environmental Features, included four sub categories: spatial shield, body shield, body direction and seating as shield. Participants also noted Staff Accommodation as a strategy for coping with the environmental stressors with 22 percent of utterance s (n=34). Category Sub Category Code Freq. % Unit Design Control of Environmental Features The ability to manipulate the features that surround the infant's bed (LTC + NSC) CEF 118 78 Lighting Controllability Control of lighting source s LTC 18 Noise Controllability Control of sound/noise NSC 20 Spatial Controllability Physical barriers between an individual and others (SPS + BDS + BDY + STC) SHD 80 Spatial Shield A screen, crib, Isolette or incubator; used to shi eld bedside space from others SPS 54 Body Shield A nursing cover, blanket, jacket or sweater; used to shield the mother's body from view BDS 21 Body Direction Mother physically turns body away from others BDY 4 Seating as Shield Back of chair used to shield mother from others SAS 1 People Staff Accommodation Nurses help to overcome a potential stressor NSA 34 22 Figure 4 9 Content analysis of participant utterance s related to coping with environmental stressors ( n =152) S patial p rivacy As reported by utterance analysis, 64 percent of interview utterance s related to environmental features (n=35) were about the spatial layout of the unit design.

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76 C omments regarding spatial layout of the open bay environment included reference s to personal ant Encroachment Mothers generally appear to be either more accepting of the necessary encroachment unto allocated or perceived personal space in a healthcar e setting, or else more traumatized by it due to the additional uncertainty about their designated space violations during lactation in an open bay NICU. The content analysis by respon dents revealed that 58 percent of participants (n=11) have felt their body was exposed at some point during their visit to the unit. One respondent shared her experience : Well, after the [caesarean section] you kind of loose your modesty, to be quite hones t with you. But yes, even with the screens, there are always st here to help, so that It does The other 42 percent (n=8) revealed to have felt their body was either well covered when performing private tasks, performed lactation tasks in the enclosed milk expression room, or accepted the necessary personal space violations while in the NICU setting.

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77 Controllability Utterance analysis of interview responses indicated that mothers used a number of strategies within their designated space a more spatial and visual privacy. Out of 118 references to the control of enviro nmental features, 68 percent (n=80) were about spatial controllability in an effort to provide spatial privacy. The most frequently cited strategi es were: using between 1 to 3 mobile screens; using an incubator, Isollette, crib or large chair as a screening device; covering themselves with a nursing cover or blanket; and turning their body. These strategies can be clustered into sub categories of s patial controllability including: spatial shield (68%, n=54), body shield (26%, n=21), body direction (5%, n=4), and seating as shield (1%, n=1) as seen in Figure 4 10 The spatial shield strategies include the utilization of a screen, crib, Isollette or incubator to shield the bedside space from others, while strategies of the body shield category consists of a nursing cover, blanket, turns her body away from others to ph ysically shield her activities from view, it is considered a body direction strategy. The seating as shield category includes the strategy of utilizing the back of a chair to shield the mother from others

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78 Category Sub Category Cod e Freq. % Spatial Controllability Spatial Shield A screen, crib, Isolette or incubator; used to shield bedside space from others SPS 54 68 Body Shield A nursing cover, blanket, jacket or sweater; used to shield the mother's body from view BDS 21 26 Body Direction Mother physically turns body away from others BDY 4 5 Seating as Shield Back of chair used to shield mother from others SAS 1 1 Figure 4 10 Utterance analysis of participant interview s which relate to spatial controllability ( n =80) T here are as many individual feeding schedules as there are mothers in the NICU environment. Multiple participants reported that feeding schedule overlap caused a limited number of privacy screens to be available during pea k visiting hours (see Figure 4 11 ) In fact, respondent content analysis revealed that 95 percent of participants (n=18) always used a portable privacy screen during lactation, sometimes with the addition of another privacy device. Figure 4 11 Privacy screen similar to those found in both NICUs (www.virtualtoydrive.org). Staff accommodation. Results from content analysis by respondent indicated that the majority of participants (84%, n=16) were offered at least one type of privacy

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79 device or mechanism by the NICU staff to manage environ mental privacy during lactation. One participant only used the pump room to express milk as she was not yet Physical distance Physical distance is a key factor of spatial privacy. Ac cording to the content analysis by respondent 5 of 6 participants (83%) in the level III NICU bedside to be able to express milk or lactate The sixth mother reported ha ving enough space in the unit u began to improv e and did not need to be in the incubator. The infant was then moved to a mobile crib and placed in the space between the original incubator and a window wall which the mother perceive d as insufficient physical distance The level II NICU had a greater variance in results. Forty two percent o f mothers believed there was not an adequate level of physical distance from others ; 33 percent of participants felt there were variables to cons ider that impacted their perception of available space, such as time of day, day of week, how many infants were in the unit, mbers were visiting at the time ; and only 25 percent of mothers repor ted having an adequate amount of physical distance from others to relax and express milk or lactate. Visual p rivacy Shelter from view As established by respondent analysis of the interview s only de area provided an adequate level of shelter from unwanted observation or viewing to relax and express milk or lactate. Three of these participants specifically mentioned their answer to this question was how they felt when they were using a privacy scree n. Yet another participant stated

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80 that even though she felt the privacy level was acceptable, she would still prefer more visual privacy. Forty two percent (n=8) did not feel the area provided adequate visual privacy, and 26 percent (n=5) reported their se nse of privacy was dependent on variables such as staff accommodations for privacy or the amount of people within the unit. Lighting. Findings from utterance analysis revealed that out of 55 references to environmental features in the NICU 11 percent (n=6 ) were utterances about lighting sources that affect ed the mother or infant The interview analysis also indicated that nonetheless had the ability to individually adjust the lightin g. This was confirmed in the utterance analysis with 118 references dedicated to coping via environmental features Of these, 15 percent of utterances (n=18) were related to lighting controllability. In addition, 21 percent (n=4) of the interview responde nts did not even know they had control over the Lighting privacy measures taken by participants who knew they had controllability included using bedside switches to dim nurse to dim the lights, or closing the window covering on a window adjacent to their space. One participant was bothered by lighting in a neighboring space which she was unable to control. Another participant, who had spent time in both the Level III and Leve l [have] NICU II. A few of the participants reported fondness for the natural lighting from exterior windows in NICU III, which contributed to the brighter atmosphere in the uni t

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81 Additionally, i fluorescent fixtures in the ceiling were never illuminated in either NICU environment. Instead, the lighting source was a series of dimmable recessed down lights controlled b Furthermore, t he only lighting that was to be controlled by the mother as it was being used as a healthcare technique to i wellness The ambient lighting of NICU II was also judged to be perceived amount of ambient light delivered to the Level II NICU and that from the incubator made the incubator lighting s eem harsh in this setting. Auditory p rivacy Noise i ntrusion. According to utterance analysis of participant interviews, 55 references to environmental features in the design of the unit, 25 percent (n=14) of which were negative responses about noise intru sion Conversely, findings from content analysis by respondent indicated that 68 percent of mothers were bothered by the noise bedside; however, most mothers still reported the ability to produce milk even though they were disturbed Noise in the unit included infant monitor alarms hand washing sinks nearby, or noise from the medicine delivery system when receiving a package. One participant even th ought the monitors in NICU III were louder than the monitors in NICU II. Two of the participants who were not bothered by noise in the NICU were located in the two semi enclosed rooms with glass walls, which created noise barriers but still experienced a lack of visual privacy. Another participant who was not disturbed stated,

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82 create a d isturbance for her since she is a nurse and used to those sounds. She was, however, afraid that the noise bothered her infant. T he level II NICU is a louder environment than the level III NICU due to the more critical state of its patients and thus its higher level of medical activity. Since the infants in NICU II are in a less critical state of health, there can be more interaction with them This could also be justified given that the NICU II has less square footage yet contains more infant beds, thus tends to have increased social density Additionally, i t was perceived by the researcher that staff conversation levels were the same within each NICU environment. Controllability. Alarms, conversations, and crying infants are an inevitable part of the NI CU environment According to the utterance analysis of interviews, 17 percent of utterances about c ontrol of the environmental features (n=20) focused on noise controllability Moreover, 78 percent o f participants (n=15) believe d there was nothing they cou ld indicated by the content analysis by individual participant responses Eleven percent (n=2) reported not being bothered by the noise, and another 11 percent (n=2) found a solution or positive distract ion to diminish the noise level The techniques used to avoid the undesirable noise quality included asking a nurse to shut off an alarm, having the auditory alarm turned off in concent rat ing on the soothing music from a device brought in by a neighboring mother.

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83 Several participants shared additional comments about noise in the environment. Numerous mothers reported the nurses were pretty good about attending to alarms shortly after t hey sounded, or even sending another staff member to do so if they were not able to attend to it themselves. One participant who had already spent a long time in the space taught me how to reset it if it becomes blocked how to straighten her arm and push Overall p rivacy Milk expression, breastfeeding and skin to skin contact are private experiences for many mothers. Even though the hospital provides privacy devices and m echanisms to shelter mother infant interactions from others in the NICU, some mothers bring in their own devices to help gain refuge from the surrounding environment. According to the results of the content analysis by respondent 26 percent of participants (n=5) reported bringing in an extra privacy mechanism from home. These devices included a nursing cover, blanket or jacket to shield the mot It was also found that a few participants brought items from home for physical comfort during their time in the NICU. For instance, one participant brought in a feeding pillow to assist her in positioning the child to comfortably brea stfeed. Content analysis by respondent also suggested that 55 percent of participants (n=10) were unable to achieve the overall privacy they desired while trying to lactate at Thirty nine percent (n=7) reported achieving their desir ed overall privacy level and 6 percent (n=1) expressed occasional achievement.

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84 Conclusion In summary, findings related to participant characteristics, lactation, stress, privacy and unit design range were discussed. The key results from the demographic inf ormation collected by the questionnaire reported that all of the participants had at least attempted lactation at the time of study, half had reported having other children, 40 percent reported having previous lactation experience, and 60 percent of the pa rticipants thought of themselves as having an introverted personality. Findings from the Parental Stressor Scale embedded in the questionnaire established that the most stressful experiences were those related to parental role alteration, yet environment al experiences were not found to be as stressful as anticipated. Nonetheless, the p articipants for who m these were negative experiences, and also gave the highest ratings to the environmental category of experiences were those individuals located at key i ntersections of circulation This location most certainly contributed to response s to the environmental stressor s Utterance analysis of the focused interviews established that the largest amount of references to environmental stressors were on the environmental features of the unit design, such as spatial layout, noise intrusion and lighting influence. It was also revealed that the largest amount of utterances regarding how participants coped with environmental stressors were related t o control of those environmental features, including spatial, noise and lighting controllability. Additionally, a ll but one of the participants in NICU III felt there was adequate spatial privacy for lactation; however, NICU II participants showed greater variance in their responses. Findings from the content analysis by respondent indicated that 68 percent of participants in both units felt there was not enough auditory privacy for lactation.

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85 Similarly, unwanted noise was reported to be the primary distra ction that kept participants from lactating. With these findings, it is not surprising that 55 percent of participants found they were unable to achieve the overall privacy they desired while Through archit ectural analysis of each open bay unit, it was found that the Level III NICU complied with the bedside space and privacy standard from the Recommended Standards for Newborn ICU Design but the Level II NICU did not. Therefore, the design of NICU II does no t provide the minimum space prescribed for privacy, nor to address the complexity of care needed for family involvement at bedside. Given these spatial constraints, observations were made which found n on verbal behavior of chair positioning signaled an indi participants faced inward from the circulation path which indicates a preference for isolation.

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86 CHAPTER 5 DISCUSSION The purpose of this case study was to evaluate the physical environment of an open bay neonatal intensive care unit ( NICU ) to discover the extent to which its features mother when performing lactation at bedside. Much of the current literatu re on NICU design is focused on staff interactions with the environment, evolvement of floor plans from the open bay to single family room configuration, and the affect different NICU entered on the lactation and the affects the environmental features have on these experiences. s with the physical environment during the process of lactation, as well as determine if privacy features in the open bay configuration contribute to environmental stress. Below are the main highlights which connect findings to the s ificance Findings revealed that participants who gave the highest score to the Sights and Sounds category of environmental stressors on the Parental Stressor Scale: Neonatal Intensive Care Unit ( PSS:NICU ) rating scale were those located at key intersect ions of the circulation path in each unit, yet these experiences overall were not found to be appearance. In fact, the most stressful experiences in this sample group were those stressors related to alteration of the parental role. Findings from this study also revealed environmental features of the unit design as the most important factor in regard s to environmental stressors ; f ollowed by furniture

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87 and family intrus ion It was discovered by architectural analysis that the environmental features in the Level III NICU complied with the space and privacy standards set forth by the Recommended Standards for Newborn ICU Design for an open bay unit, but the Level II NICU d id not. Interestingly, 64 percent of participant utterances were about the spatial layout related to environmental features in the unit design (n=35). Spatial layout comments were generally negative and included references to personal space, the space bein g open, distance from others, room configuration or private rooms. Additionally just over half of participants found at least one of the seating options comfortable enough for lactation at the bedside space, even though there was not a chair that was an o verwhelmingly preferred choice. In order to cope with the environmental stressors in the unit, m others were observed spatially orienting their chair in whatever direction felt most comfortable or most private in the bedside space. T he largest amount of pa rticipants chose to face inward away from the circulation path which indicted their preference for isolation In addition, participants mentioned other ways in which they coped with environmental stressors. T hese comments indicated that the most signific ant category of utterances was control of the environmental features which claimed 78 percent of the comments; while the other 22 percent of utterances was about coping via staff accommodation The findings also uncovered a link between environmental priv acy and the configuration of each unit. The majority of participants (83%) in NICU III where beds are placed at larger physical distances from one another, felt there was an adequate amount of spatial privacy Conversely NICU II where beds are physicall y closer to each other, contained only a quarter of participants (25%) that were satisfied with the

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88 spatial privacy. Contrary to the split findings of spatial privacy, the majority of participants in both units felt there was not adequate visual privacy (4 2%, n=8) or auditory privacy (68%, n=13) for lactation activities. In addition, 68 percent of references to control of environmental features (n=80) were regarding spatial controllability in an effort to provide spatial and visual privacy, whereas only 17 percent of utterance s were about noise controllability. As briefly highlighted above, t his chapter discusses findings in regards to the which includes maternal characteristics and stress, as well as environmental privacy, which features discussion of frequent issues, location in the unit experience in the open bay NICU environment as well as implications for future research on this topic Materna l Characteristics Time in the neonatal intensive care unit Data from the interview instrument confirmed that every mother who participated in bedside. This perhaps occurred reason for visiting the NICU, yet could have also occurred due to the limited spaces designed for family members to spend time. The only other spaces accessible to NICU mothers were the milk expressio n room and the family waiting areas. While televisions, magazines and internet access were provided as entertainment in both waiting rooms, access to nature was not afforded.

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89 The number of days each participant reported that their infant had spent in the N ICU was revealed by the questionnaire results which highly varied from two to 77 days Further research is needed to find out if the length of time the infant has been in the NICU correlates with a change in the comfort, satisfaction, perception of privac y or perception of stress experienced by the mother. The questionnaire provided information which showed that t he average amount of time each participant spent visiting their infant in the NICU varied from three to twelve hours per day The length of time per day each mother spent with their infant did not correspond with their employment status nor did it link to any other demographical statistic such as age, marital status, family income schooling or whether they ha d other children Additional research with a larger sample may possibly uncover statistical relationships in regards to time Lactation Jaeger et al. (1997) establish ed that even in the best of conditions breastfeeding was a challenging task for many women and that facilitation of breastf eeding in the NIC U can be particularly difficult. Yet questionnaire findings indicated that all but one individual in the participant sample had the ability to lactate at time of study, with 60 percent having breastfeeding success. This findin g suggests that the built environment did not play as significant a role as expected in facilitating lactation, meaning that motivation is a greater force than environmental influence. Perhaps this occurrence could instead be attributed to the timing of in formation each mother received before the birth of their infant. Lessen and Crivelli Kovach (2007) reported a significant correlation between the breastfeeding information mothers received prenatally and postpartum with the initiation of lactation; as moth ers who received knowledge

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90 prenatally were more likely to initiate lactation than those who were informed of lactation benefits postpartum. As Furman and Kennell (2000) and Talmi and Harmon (2003) point out, there are few opportunities for relaxed and int imate interactions for parents with their hospitalized infant, which typically produces a great deal of stress and emotional turmoil for the parents. However, skin to skin care can be a stabilizing experience for the mother and infant and provide an opport unity for intimacy (Furman & Kennell ; Talmi & Harmon) Seventy five percent of participants in this study were able to make skin to skin contact with their infant before a lactation session, which conceivably had positive emotional effects on the mother in fant connection (Hurst et al., 1997) and aided the transition from gavages and bottles to breastfeeding (Lessen & Crivelli Kovach, 2007) Maternal Stress Previous e xperience Spear et al. (2002) determinin g factor for the degree of stress they suffered. Mothers without a previous infant were considered to have less ability to cope with stress than more experienced mothers ( Spear et al. ). In this study however, there was no conclusive evidence that having an other child or previous lactation experience determined the degree of stress. Experienced mothers tended to report overall st ress levels similar to inexperienced mothers. This finding could suggest that the intensity of the stress related to having a prema ture child and all of its associated emotional and financial ramifications override the effect of previous experience. Further research on psychosocial issues affecting NICU mothers might explore whether this is the case.

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91 Internal p sychology Another factor Spear et al. (2002) related to the degree of stress suffered by the maternal population was their internal psychology. Introversion and extroversion were the internal psychology characteristics used in this study to determine how a mother would cope in th e unfamiliar NICU environment. It was hypothesized that introverted mothers would have a more difficult experience in, or a harsher opinion of, an open bay NICU due to their hesitance to engage with others with whom they are unfamiliar. It was also thought that introverts would have trouble with the lack of permanent physical barriers which separate their space from others. Findings in this study indicate slight differences between the experiences of introverted and extroverted mothers. Sixty percent of par ticipants reported an introverted internal psychology, 35 percent reported an extroverted psychology, and five percent, or one participant, opted not to answer the question. Of the respondents it was found that the combined PSS:NICU scores of the introver ts were higher overall than the scores of the extroverts. In other words, on a moderately high median lower median score of 2.93. Perhaps this was because introverts found violations of the ir designated space to be more stressful than extroverts, whereas extroverts feel more comfortable 2009 ). viewed as stress when the environmental load exceeded the limits of their coping capability This theoretical framework related to the findings in this study through the

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92 internal psychology factor of extroversion and introversion. Related findings were about the differences that exist between the experiences of introverted and extroverted mother s as the combined parental stressor scale scores of the introverts were higher than the scores of the extroverts. An a dditional finding rel ated to the theoretical framework was the discovery of highe r environmental stress level s reported by introverts l oca ted at key circulation intersections in each unit, whereas the extrovert that was located in the same region reported the only lower environmental stressor score relatively speaking N eonatal intensive care unit experiences In the PSS:NICU instrument, e xperiences are divided into three categories: Sights and Sounds, Baby Looks and Behaves/Treatments, and Relationship with Baby/Parental Role. Overall scores for each of the three categories, as well as individual participants, were able to be determined by utilizing the self reported information of this instrument. Average scores for each individual PSS:NICU experience were determined then r anked from the most to the least stressful experience. The highest ranking experience Relationship with Baby/Parental Role category of the instrument. This study confirms the findings of Carter et al. (2007) Dudek Shriber ( 2004 ) and S e id e man et al. (1997) which report the experiences in the Relationship with Baby /Parental Role category as the top set of stressors, with the Baby Looks and Behaves/Treatments category of experiences rating second highest. These findings conflict with a study by Miles et al. (2002), which observed stressors in the Baby Looks and Behav es/Treatments category to be the top cause of stress in the NICU. However, the literature did not report the unit configuration

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93 for either of these studies; therefore, future studies are needed with larger sample sizes and varying configurations The sa me list of ranked stressors revealed all environmental experiences to be located near the bottom of the list and with lower scores, which indicates that these experiences were not found to be as highly stressful to mothers as many other items from the Rela tionship with Baby/Parental Role and Baby Looks and Behaves/Treatments categories. This may have occurred because the inherent strength overridden the effect the NICU e nvironment had on mothers. Other explanations were offered by Dudek Shriber (2004) for the lower environmental stressor scores, which familiarity with intensive care units via media outlets, and parental experience that may have prepared them for the NICU environment. In this study, the median of the Sights and Sounds category of the PSS:NICU, the category which contains the largest number of environmental experiences, land ed at the center of the five point scale, or 2.49. Yet it was found that not all experiences relating to environmental privacy were included in the instrument. This indicates that this instrument may not accurately illustrate a true stressor score for all environmental qualities. Qualitative findings in the study relating to privacy mechanisms suggest influences that were missed in this category, which indicates that further research on inclusion of these stressors may help determine whether environmental q ualities mother.

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94 When cross referencing the individual scores of the Sights and Sounds category to the location of each participant within each unit, it was found that pa rticipants located near key intersections of the circulation path reported the highest level of environmental stress, or highest Sights and Sounds scores. In conjunction with this finding, all but one of the participants located at the key intersections ga ve a relatively high Sights and Sounds score of 3.0 or higher on a scale of 1 to 5 The one participant who reported a lower score was the only one in this group who reported having an extroverted internal psychology, which meant they have an interest in p eople and activity, and are intersections were introvert s who preferred inner reflection over activity and were more stressed by their location in the NICU environment Overall stressor s cores For the PSS:NICU instrument, there were two scores for each participant that experiences per individual, comprised of the individual scores from the three PSS:NICU averaged together to produce this combined score, with the final score being rounded to the hundredth decimal place. The second overall score refers t o the question from the 3). This overall score was rated similarly as the indiv idual experiences in a five point any other score.

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95 r respondent 75 percent of the time, with the exception of five participants who reported the opposite. On a scale of 1 to 5, the was 3.71. Even though they are both cons idered moderately stressed scores, this finding could indicate that there are more environmental privacy experiences in the open bay NICU that are not currently being captured by the PSS:NICU instrument. This claim is supported by comments made by two of t he participants. It is worth noting that these comments were made prior to exposing the participants to questions about environmental privacy during the interview, although they were told the main focus of the study prior to agreeing to participate. One pa : The entire experience is not one that I wish to repeat or have anyone go through if not absolutely necessary. Some tests were not accurate and this was very stressful. We eventually fixed the problem; however, the timing was very bad and unavoidable. PRIVACY would have be en very important and still is. Ou t of nin e participant who left comments, t he other seven commented about stress related to the separation from their infant, which includes not being able to stay with the infant overnight and not being able t o take the infant home; lack of communication between doctors and parents for instance, the inability to speak to the doctor if the having different caregivers for examp le not being able to have a constant person that is taking care of their infant; and not knowing an exact release date for their infant.

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96 ocated adjacent to areas of high activity, such as the unit entrance, medicine storage, family rooming, and nurse station, usually with two or more pockets of activity nearby (see Figure 5 1 ). This seems to indicate that located near high occurrences of activity are likely to report higher overall stressor scores for their experience in the NICU environment. Additionally each of the participants who gave the ir NICU experience the highest possible stressor rating reported t heir internal psychology to be introverted, meaning that these individuals prefer inner reflection over activity and are happiest when alone lowest stressor scores did no t belong solely to extroverts. A

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97 B Figure 5 1 Location of participants with the highest overall PSS:NICU scores. A) NICU III and B) NICU II Environmental Privacy This study has revealed environmental privacy issues missing from the PSS:NICU instru ment which could improve the instrument if they were added. These privacy issues include the adequacy of visual privacy, or shelter from unwanted observation, and spatial privacy, or distance from others and designated space, provided to each participant. Recommendations are given later in this chapter as t hese environmental privacy issues should at least be considered during scoring as they may determine the discrepancy in the overall perceived stress ratings of the parental population Frequent Issues A ccording to the utterance analysis of participant interview s two groups of utterances were discovered within the original set of participant comments: those about perceived environmental stressors and those related to coping with them. Literature indicate s that environmental stressors are long term conditions of the physical

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98 environment that are uncontrollable and may potentially result in stress or anxiety (Devlin & Arneill, 2003; Topf, 1994; Veitch & Arkkelin, 1995). In addition, Stewart Pollack and Menc oni (2005) suggest that people respond negatively to environmental In this study, the categories that emerged in the course of the utterance analysis from the group of environmental stresso rs responses were environmental features, furniture and family intrusion. E nvironmental features was the most frequent utterance category of the three as it was mentioned 55 times and generated 49 percent of comments in this group. It was also discovered t hat two categories emerged from the coping with environmental stressors utterance s. These categories were control of environmental features and staff accommodation, with control of environmental features being the most frequent utterance category as it was mentioned 118 times and amassed interpreted to mean that privacy and satisfaction of participants in an open bay NICU heavily relies on the environmental features as well as th e control of these features. In support of this finding, literature on controllability established that the perceived relationship between an individual and their environment is essential for effective functioning as people have a strong need for control with respect to situations and environments (Stewart Pollack & Menconi, 2005). Furthermore having control with respect to a potential stressor reduces and sometimes eliminate s the negative effects of the stressor ( Stewart Pollack & Menconi ; Ulrich, 1991). Spatial configuration By analyzing each open bay NICU configuration it was found that the NICU III complied with the Recommended Standards for Newborn ICU Design Standard 3:

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99 Minimum Space, Clearance, and Privacy Requirements for the Infant Space (White, 2007 b ) while NICU II did not. T he Recommended Standards are not a requirement, yet are highly encouraged. However, this finding suggests that at the time of the NICU II renovation, the square footage of the unit was not increased to meet the recommended standard, perhaps because space for other unit features such as storage or refrigeration were prioritized. Additionally, the limited clearance between patient beds in NICU II was perhaps dependent on the hospital census demand which took precedence over the which examined the effects of physical distance on the intimacy of seating arrangements, it was found that intimacy was strongly related to physical distance. Furth er research is needed to determine priority of space allocation in an open bay NICU and to make a stronger case for physical distances between bedside spaces given the intimacy of mother infant interaction during lactation. Storage. The other 38 percent o f participant utterances regarding furniture in the NICU from the utterance analysis was in reference to bedside storage. The current the counter top or the floor at the Since both of th ese may also be in the way of the NICU staff when caring for the infant and perhaps may become a hazard, other options should be I try not to spread out that much. I try to keep my belongings pretty minim al and together. space. participant added that:

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100 down to the stuff and then, possibly need hand washing. Standard 11: Family Support Space from the Recommended Standards also has a (White, 2007b, p. S10). Seating. According to utterance analysis of participant interviews, 62 percent of comments regarding furniture in the unit were about the seating options used during lactation, while 59 percent of participants agreed that the seati ng at bedside had provided an adequate amount of comfort for lactation activities. Even though more than half of participants found the seating options acceptable, they were unable to agree on their favorite chair. The variance in seating preference is cle arly the reason why NICUs are designed with seating options. One participant who claimed liking different chairs for rocking chairs seat get a little hard, so the nurses will bring you a pillow. Or they have rock him for a little bit, then I get the recliner. Standard 11: Family Support Space from the Recommended Standards for newborn ICU design suggests comfortable seating be provided for lactation (White, 2007b), which can be interpreted to mean that comfort strategies for dif ferent body types should be accommodated for use during milk expression and breastfeeding

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101 Spatial orientation Directional or ientation is interpreted as non verbal communication that may signal openness to communicate or whether interaction is welcomed ( Gi 1986; Stewart Pollack & Menconi, 2005). According to observations in both NICU varied with 65 percent of mothers facing inward from the circulation p ath which indicated preference for isolation One of the se participants indicated using the chair back as a privacy mechanism, which supports the theory However, alternative chair could have been directionally oriented by a nurse upon arrival, or perhaps the participant could have felt unable to reorient the chair due to the spatial limitations of the bedside area Spatial p rivacy U tterance analysis of participant i nterviews also determined that the most frequent sub category of environmental features or 64 percent of utterance s, was in regards to spatial layout of the unit ; including references to personal space, the space being onfiguration or private rooms. Th is finding infers that the layout of the unit was the overwhelming environmental feature that had an effect as a stressor on participants Recent studies h ave previously concluded this which is perhaps the reasoning for th e shift to the single family room (SFR) unit configuration s Shepley et al. (2008) explain that SFR units support privacy for parent infant interactions better than open bay units and are viewed to be a less stressful unit configuration as the individual r ooms provide families with improved environmental privacy, as well as sleeping and waiting areas. Stewart Pollack and Menconi (2005)

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102 therefore claim that the challenge is for open bay NICUs to provide as much control and individual privacy within the limit ed space as the SFR units Similarly, the most frequent sub category related to control of environmental features from the utterance analysis was spatial controllability, with 68 percent of utterance s. Spatial controllability strategies include using a sp atial shield or a body shield, manipulating body direction and positioning the seating to use as a shield. These findings were interpreted to mean that mothers heavily rely on spatial control mechanisms to create their desired privacy. According to Stewart Pollack and Menconi (2005), controllability is one of the most important factors influencing perceived privacy and stress levels for mothers in a health care environment ; therefore, control of personal space is important in establishing privacy requiremen ts (Human Behavior and Interior Environment, 1997) so it does not develop into further stress for the individuals More than half of the mothers in this study felt that their body had been exposed at some point during a lactation session in the NICU. This can be interpreted to mean that at some point while expressing milk or breastfeeding, these mothers were not w ell covered by a privacy control mechanism. Each individual has their own levels of modesty, or reserved behavior which determines the level of s patial violations they are able to accept. Additionally, those mothers that experienced moments of exposure gave reasons why they felt the personal violations were unacceptable which included: unfamiliar staff circulating; other parents in the unit, speci fically fathers in neighboring bedside spaces; and groups touring the unit. Literature indicates that the more intimate the spatial relationship, the more people refuse to accept intrusion by others (Human Behavior and Interior Environment, 1997).

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103 Visual p rivacy Shelter. Lactation activities such as skin to skin care, milk expression and breastfeeding are private experiences for many mothers who prefer to perform these activities unobserved. In this study, it was found that 42 percent of participants felt t he environment did not provide an adequate level of visual privacy during lactation. Similar to the effects felt by a lack of spatial privacy, m any m others acknowledged the existing visual privacy mechanisms we re greatly relied up on to create a level of pr ivacy where they could relax and let down This aligns with the literature by Burden (1998) who claimed that visual privacy is needed, especially by new mothers when begin ning to gain lactation skills, as time is needed to experiment with their bodies wit hout judgment from others in case they fail. Lighting. Even though only 11 percent of references to environmental features from the utterance analysis were about lighting sources, and 15 percent of references to coping with environmental features related t o lighting controllability, the majority of participants, or 79 percent of the maternal sample, knew they had control of the lighting the unit was designed to give m others control of their individual bedside lights, but because most of the participants had been informed by the staff of individual controllability. In addition, one of the participant s indicated that she liked the natural light from the windows adjacent circadian rhythm. To support this thought, a study by Stevens, Akram Khan, Munson, Reid, Helseth & Buggy (2007), which examined the change in the NICU environmental sound and illumination in relations hip to a single family room facility as compared with a

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104 conventional NICU, found that neonates could be exposed to extremely high levels of natural illumination in exterior rooms Auditory p rivacy Noise i ntrusion. Although the utterance analysis of partici pant interviews reported that only 25 percent of comments regarding environmental features in the unit consisted of utterance s about noise in the unit, a total of 68 percent of mothers stated that they were bothered by the noise level in the unit. Perhaps personal levels of auditory tolerance can be attributed with the slight variance of respondents who reported being bothered by noise during lactation. Stewart Pollack and Menconi (2005) support this idea and report that the effect of noise v aries for each individual and is dependent on personal and environmental factors. Controllability. Seventy eight percent of participants believed there was nothing they could do to control the unwanted noise that invades the bedside space; however some mothers found a w ay to control noise for themselves, such as asking the NICU staff to shut off an alarm playing r elaxing music having the auditory alarm on the while breastfeeding so only the light flashes. This finding can be interpreted to m ean that most mothers accept the noise disturbances as they assume the disturbances are a necessary part of the hospital setting. However, Philbin (2004) suggests that in an open bay NICU, sound absorbing surfaces on the walls and ceiling will help to prev ent noise from bouncing back into the space. In addition, circulation and open staff work areas need to address protection of the open infant space from the noise generated by activities not directly related to infant care (Philbin).

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105 Location in the U nit In the Level II NICU, confirmed that all mothers located in the row of infant beds closest to areas of high activity did not report achieving any of the environmental privacy e (see Figure 5 2 ). These privacy factors include visual privacy, auditory privacy, physical distance and personal space, as well as achievement of desired overall privacy. Participants who reported adequacy of at least one type of these privacy factors we re located in the second and third rows of infant beds, past the partial obstruction of cabinetry and equipment storage which divides the NICU into two sections. This indicates that a partial physical barrier from high activity may increase the adequacy of environmental privacy for lactating mothers. In support of this finding, Philbin (2004) explains that in an open bay NICU where full walls are not able to be added to lessen noise intrusion, carefully designed partial barrier walls can play a role in nois e controllability. It was suggested that increasing the height of the barrier will ease the sound diffracted over the top of the barrier, and increasing the length or turning the ends toward the source of the loudest noise will ease the sound that is diffr acted around the edges. It was also noted that infant bedsides near the partial wall may be more protected from the sources of noise than the infants at a distance from the partial barrier (Philbin).

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106 Figure 5 2 Environmental Privacy Issues in NICU II. Two participants in NICU II reported achieving all of the environmental privacy indicators, including desired overall privacy level. These two mothers shared conditions favoring privacy which were uncovered by this study Both mothers were located in the second row of infant beds with the barrier of cabinetry and equipment separating them space in the middle of the row, not near an end or intersection, and they chose to mothers and their infants had been admitted between 20 to 30 days prior to this study, infant in the NICU, or that at the time they were familiar enough with the space to create their desired level of environmental privacy in the bedside space. Additionally, both mothers

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107 stated that they were currently able to lactate and were successful at making skin to tolerance for any privacy violations that may have occurred. Addit ionally, the two mothers were unemployed at the time of the study, which may have afforded them more time to spend with their infant without the additional job related thoughts or stressors. Finally, they both had other children and therefore had previous experience caring for a recommended to determine whether these conditions favor all mothers who are comfortable expressing milk or breastfeeding in an open bay NICU Staff A ccommodation Eighty four percent of participants reported feeling a sense of accommodation by members of the NICU staff when preparing for and during a lactation session. In a study by Lessen and Crivelli Kovach (2007) which examined maternal, neonatal and outside influences associated with feeding intention, it was found that assistance from nurses and other medical staff is needed for mothers to feel more confident in the environment, as well as their breastfeeding abilities. One of the parti cipants described her experience: F that everyone of the nurses included, made sure that we had the comforta doing everything that they possibly can to help. really accommodating a nd very parent how to take her out, how to do everything with her. I can change her diaper

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1 08 comfortable doing all of that T hey Do you need anything but if not, they just let me do what I need to do. Reco mmendations for Environmental Privacy and Comfort A major motivation of this research was to recommend design solutions that will limit the environmental privacy issues from becoming additional sources of stress to mothers in the NICU. The findings from th is study as well as previous research provide guidance to these recommendations which could be applicable to future open bay NICU designs. Below are recommendations which center on environmental features and Preferences The factor found in this study which most commonly accounted for maternal stress was the internal psychology factor or whether the individual was an extrovert or introvert One introverted participant described her experience: Well, the reason [the infants] move [location] is because of the different nurse shifts. They usually try to give [the infants] the same area, but it warned me that she might be moved, so I was okay. The second time was Future research is recommended to determine whether internal psychological traits do, in f act, determine the degree of stress perceived by lactating mothers. Perhaps each is admitted to the NICU, which is important as the mothers may particularly benefit fr om identification that could define the ir best location in relationship to key circulation intersections, perhaps reducing anxiety and perceived stress levels. Additionally, the PSS:NICU instrument could be combined with another instrument specifically des igned

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109 to measure internal psychology or personality, such as the Meyers Briggs Type Indicator (MBTI), so that personality type could be more accurately measured in the future. Along the lines of this recommendation, Dudek Shriber (2004) also recommends tha t occupational therapists or other health care practitioners should determine the perceived stressors of the parents to better address their needs reduce their stress and enhance their ability to understand the situation and cope with their hospitalized infant. Spatial and Visual Privacy Sixty eight percent of all either never provide d an adequate level of shelter from unwanted observation or viewing to relax and express milk or lactate or that their sense of privacy was dependent on variables such as staff accommodations for privacy or the amount of people within the unit at the time Some of the participants even reported needing multiple privacy devices to feel even a semblance of privacy, as described by o three at one time and a sheet in between and still not feel completely covered One recommended improvement for the Level II NICU would be the addition of translucent dividers installed above th e existing center line of cabinetry and equipment storage (see Figure 5 3) This would protect the visual privacy of mothers attempting to lactate from individuals standing on the other side of the partition without feeling visually heavy or blocking natur al light from the exterior windows This strategy already exists in the Level III NICU, and participants in this unit found there was adequate visual privacy at bedside during lactation.

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110 Figure 5 3 Cloud shaped translucent partition (www.3 form.com ) Without the visual separation of solid walls, an open bay unit should invest in additional privacy screens to increase the amount of visual privacy for lactating mothers at the bedside space In support of this recommendation, one participant claimed: Like, my husband, last night, he was in here, and he said he turned and she starting to breastfeed, so she the bedside too and feeding him. This view is also maintained by Altimier (2004) who states that promotion of privacy in turn, increase s mother child interaction S ince there is limited space to store the bulky screens that are currently in use and more of them would only clutter the already limited space screens with a thinner profile and lightweight aesthetic should be considered s ince they take up less storage space. A

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111 flexible system of folding p anels should also be considered which could be portable, extend from the cabinetry or be maneuverable on a track in the ceiling. Auditory Privacy Sixty eight percent of participants were bothered by an inadequate level of shelter from unwanted noise at Noise from monitor alarms, adult conversations, and crying infants is unavoidable in the NICU environment and was reported to be the primary environmental distraction that kept participants from initiating lactation. Seventy eight p ercent of participants believed there was nothing they can do ind of like an open Ever ything is out there for everybody to hear. Unfortunately, the noise from the NICU can be detrimental as mothers need to hear the i nfant cues include sucking, smacking, cooing, and crying (Hurst, 2007) which are i mportant in initiating lactation Noise c ontrollability. Much of the noise in both NICUs is comprised of reflected noise as most of the surfaces are made of hard materials with the exception of the small amount of fabric of the privacy screens, vinyl recliner chairs, and linens used in the infan Specifying sound absorbing ceiling tiles is not enough to create an environment that minimizes noise reflection in the open bay NICU setting. Sound absorbing acoustic al panels affixed to the walls could go far in alleviating some of the reflected noise. Contemporary, acoustic fabric is available in many colors as well as in printed patterns that can camouflage into the environment. Literature by Evans and Philbin (2000), in which architectural design and construction for achieving quiet nursery en vironments are discussed, supports the need for acoustically absorptive surfaces.

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112 They found that absorptive materials should be placed on both vertical and horizontal surfaces to control sound reflections on their first or second bounce; and can also be b eneficial through control of random incidence reflections (Evans & Philbin). Also to be considered are the to mask noise in the unit and rubber flooring to absorb the sound from impacts such as dropped items, rolling carts and noise from shoes Rubber flooring is resilient, easily cleanable, highly durable, recyclable, provides a cushioning effect and appropriate for healthcare environments which are factors that should outweigh the initial cost of installation (White, 2007a) Newer equipment and monitors have the ability to use visual alerts, such as flashing lights, and vibratory alerts, such as radiofrequency communication with vibrating pagers worn by the NICU staff. It is recommended that this technology be considered fo r alarms of less severity, especially when the mother is attempting a lactation session ( Walsh Sukys, Reitenbach, Hudson Barr, & DePompei, 2001). Positive distraction. Another recommendation for auditory privacy during lactation sessions is to provide ind ividual music or television machines which can only be heard though a headset that the mother can bring with her This strategy is and having the mother focus on soun ds that are more pleasant and personalized to help them relax. This recommendation is supported by (1991) which cites access to positive distractions in physical surroundings as one of the components that helps families cope with stress.

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113 Furniture Storage. Even though this unit is unable to increase physical distance between patients without lowering capacity per unit, there are ways to increase storage for personal belongings which may in turn create more bedside space for each individual and give the perception of increased physical distance. Dedicated storage could be created there orage space should be large enough for a tote bag and sweater, and possibly a small blanket or nursing pillow. According to White (2003), this personalization strategy is already being provided in SFR unit configurations as these rooms give families the op portunity to make their This sentiment is supported by Add itionally, Williams (2001) suggests that careful consideration should be given view as a board to display cards and family pictures as well as a space for personal belongings would go far in making the unit seem more familiar, and less te chnical and intrusive (Williams ). Seating. The seating provided in the current units were not an overwhelming adequate comfort during lactation. However, improvements are still recommended to raise this percentage. The number of recliner chairs could be increased as it was the top seating selection of the participants in this study. One of the participants stated that, We have to fight over these [recliner ] chairs. I mean, that o Another recommendation is the addition of rotating

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114 chairs that facilitate the orientation of the user. This would give mothers better control to indicate preference f or isolation by simply rotating the chair while remaining seated. C ushioned glider chairs could also be a positive addition to the unit since they combine the rocking motion of the rocking chair and the cushioned seat and back similar to the recliner chair If the addition of glider chairs is not an option the addition of detachable cushions to the existing rocking chairs should be considered (see Figure 5 4) The cushions should b e made of durable high performance fabric that is inherently resistant to v arious fluids and stains. Cushions are necessary for mothers who have just given birth and who need to sit for extended periods of time These cushions would especially help those mothers who have undergone abdominal trauma and find the ergonomic structure of the rocking chair superior to those of the recliner chair, to have greater comfort during the lactation experience. Figure 5 4 Similar cushion for existing rocking chairs (www.therockingchaircompany.com).

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115 Implications for Future Research Given t he lack of research in this area, this study should be perceived as exploratory. Further empirical research on the implications of the various environmental privacy factors is needed, in particular the privacy mechanisms each open bay unit employs for indi viduals to gain control of their designated bedside space. Research on staff preferences and interactions with the privacy mechanisms used during maternal lactation is needed, particularly to determine whether additional stress is sustained by the NICU sta bay NICU studies should compare more than one case to produce results that can be generalized The current version of the PSS:NICU covers most, but not all, of the potential stressors f ound in a NICU setting. It falls short of including all of the potential stressors related to noise in the unit, it fails to include items related to spatial and visual p rivacy. Recommended changes to be made to the PSS:NICU would be to include items under the Sights and Sounds category, such as: The physical distance from others in the unit The amount of bedside space provided to me The adequacy of shelter from unwanted observation It is also recommended that Environmental Qualities be added to or be the replacement for the Sights and Sounds category name. Finally, given that this study has centered on i nfant s mother s during a single visit to the NICU environment wher e the participants were in different stages of environmental familiarity and lactation a longitudinal study of

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116 from first admittance to discharge of her infant would be valuable to uncover whether environmental privacy had an impact on timing of lactation stages. Conclusion The Level III NICU utilized in this study achieved more of the recommended standards for environmental privacy design than NICU II, yet noise in both units impacted lactating mothers more than any other environme ntal privacy factor due to auditory privacy being the feature over which mothers had the least amount of control of their environmental privacy conditions do affect th eir overall experience in an open bay NICU, as over half did not achieve their desired privacy levels. However, the stress was unable to be made through the use o f the par ental stressor scale. Despite this, the perceived stress levels recorded were similar among study participants in both units which indicates the participants were not affected by the environmental privacy tressors in an open bay NICU. the promotion of the parental role through control of the built environment to gain privacy and reduce the effects of environmental stressors In the future, p articular attention needs to b e directed towards placement of the mothers within the open bay unit according to their internal psychology, which plays a role in how the individual copes with environmental stressors Mothers should also be afforded individual control of the spatial and visual privacy mechanisms in order to feel comfortable performing intimate activities such as breastfeeding This sense of control was proven to be an important factor that influenced s stress level and

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117 contributed to mother infant bonding Finally, it is important that auditory privacy strategies remain in the forefront of NICU design since unwanted environmental sounds were reported to have a negative effect on the individu al s when attempting to perform lactation, which requires relaxation.

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118 APPENDIX A INSTITUTIONAL REVIEW BOARD LETTER OF APPR OVAL

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119 APPENDIX B INFORMED CONSENT DOC UMENT

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120

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121 APPENDIX C CERTIFICATE OF COMPL ETION FOR HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT & PRIVACY RESEARCH

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122 APPENDIX D PERMISSION TO USE PA RENTAL STRESSOR SCALE : NEONATAL INTENSIVE CARE UNIT RESEARCH INSTRU MENT

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123 APPENDIX E INTERVIEW QUESTIONS For identification purposes only, please write a six character alphan umeric combination with your first and last initial and month and day of birth (e.g. JP0706). CODE IDENTIFIER: __ __ __ __ __ __ ( FI, LI, M, M, D, D) PART 1: Environmental Privacy These are open ended questions where the participant will be able to speak in detail about their experience in the Neonatal Intensive Care Unit (NICU). 1) shelter from unwanted observation or viewing for you t o relax and express milk or lactate ? ______ yes ______ no Please explain: _____________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________ _______________ 2 ) If you are bothered by lack of visual privacy in the NICU, what can you do? (check all that apply) close the privacy screen ask someone else to close the privacy screen move into a private room do nothing other, plea se specify __________________________________________ 3 ) If you are bothered by the lighting in the NICU, what can you do? (check all that apply) dim the lights ask someone else to dim the lights turn off some of the lights ask someone els e to turn off some of the lights close the curtains ask someone else to close the curtains do nothing other, please specify __________________________________________ 4 ) shelter from unwanted noise for you to relax and express milk or lactate ? ______ yes ______ no Please explain: _____________________________________________________________________________ _________________________________________________________________ ____________ _____________________________________________________________________________ 5 ) If you are bothered by too much noise in the NICU, what can you do? (check all that apply) turn off the alarms ask someone else to turn off the alarms ask people to be quiet do nothing other, please specify __________________________________________

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124 6 ) physical distance from others for you to relax and express milk or lactate ? ______ yes ______ no Please explain: _____________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________ _______________ 7 ) space for your personal use ? ______ yes ______ no Please explain: _____________________________________________________________________________ _________________________________ ____________________________________________ _____________________________________________________________________________ 8 ) Have you felt your body was exposed at any time during your visits in the NICU? ______ yes ______ no If YES, please explain: ____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 9 ) Have you been offere d to use any type of privacy devices while trying to express milk or lactate ? ______ yes ______ no If YES, please explain: _____________________________________________________________________________ _______________________________________________________ ______________________ _____________________________________________________________________________ 10 ) d side to be more private ? ______ yes ______ no If YES, please explain: _____ ________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 11 ) Have you brought in any privacy devices to help relax and express milk or lactate ? (e.g. headphones, extra blanket, etc.) ______ yes ______ no If YES, please explain: _____________________________________________________________________________ _________________________________ ____________________________________________ _____________________________________________________________________________ 12) express milk or lactate ? ______ yes ______ no

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125 If NO please explain: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 13 ) What is the biggest distraction while in the NICU that keeps you from initiating lactation? _____________________________________________________________________________ _____________________________________________________________________________ _________ ____________________________________________________________________ 14 ) express milk or lactate ? ______ yes ______ no Please explain: _______________________ ______________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

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126 APPENDIX F PARTICIPANT QUESTION NAIRE For iden tification purposes only, please write a six character alphanumeric combination with your first and last initial and month and day of birth (e.g. JP0706). If you were selected to participate in this study, you may be asked to use this code identifier again CODE IDENTIFIER: __ __ __ __ __ __ (FI, LI, M, M, D, D) PART 1: Visiting in the Neonatal Intensive Care Unit (NICU) For questions 1 4, please select or insert the most appropriate answer. 1) How long has your baby been in the hospital? __ ____ days ______ weeks 2) How many times did you visit in the last week? ______ times 3) What is the average length of your visit? (approximately) ______ hours ______ minutes 4) Where did you spend most of your time while visiting? edside In NICU, not at bedside Milk expression room Quiet room Other, please specify: ___________________________ PART 2: Activities W hile Visiting the NICU For questions 5 8, please select the most appr opriate answer. 5) Are you currently able to lactate? yes no 6) attempted successful not applicable 7) Have you attempted or were you succes attempted successful not applicable 8) Have you been able to make skin to skin contact with your infant right before beginning a breastfeeding or milk expression session? yes no P ART 3 : Parental Stressor Scale Nurses and others who work in neonatal intensive care units are interested in how the experience of having a sick baby hospitalized in the neonatal intensive care unit (NICU) affects parents. We would like to know what aspec ts of your experience as a parent are stressful to you. By stressful, we mean that the experience has caused you to feel anxious, upset, or tense. Please indicate how stressful each item listed below has been for you using the following scale: 1 = Not at all stressful: the experience did not cause you to feel upset, tense, or anxious 2 = A little stressful 3 = Moderately stressful 4 = Very stressful 5 = Extremely stressful: the experience upset you and caused a lot of anxiety or tension If you did no t have the experience, indicate this by circling N/A meaning that you have "not experienced" this aspect of the NICU.

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127 Below is a list of the various SIGHTS AND SOUNDS commonly experienced in a NICU. We are interested in knowing about your view of how stre ssful these SIGHTS AND SOUNDS are for you. Circle the number that best represents your level of stress. 9) The presence of monitors and equipment NA 1 2 3 4 5 10) The constant noises of monitors and equipment NA 1 2 3 4 5 11) The sudden noises of monitor alarms NA 1 2 3 4 5 12) The other sick babies in the room NA 1 2 3 4 5 13) The large number of people working in the unit NA 1 2 3 4 5 14) Having a machine (respirator) breathe for m y baby NA 1 2 3 4 5 Below is a list of items that might describe the way your BABY LOOKS AND BEHAVES while you are visiting in the NICU as well as some of the TREATMENTS that you have seen done to the baby. Not all babies have these experi ences or look this way, so circle the NA, if you have not experienced or seen the listed item. If the item reflects something that you have experienced, then indicate how much the experience was stressful or upsetting to you by circling the appropriate nu mber. 15) Tubes and equipment on or near my baby NA 1 2 3 4 5 16) Bruises, cuts or incisions on my baby NA 1 2 3 4 5 17) The unusual color of my baby (for example looking pale or yellow jaundiced) NA 1 2 3 4 5 18) M y baby's unusual or abnormal breathing patterns NA 1 2 3 4 5 19) The small size of my baby NA 1 2 3 4 5 20) The wrinkled appearance of my baby NA 1 2 3 4 5 21) Seeing needles and tubes put in my baby NA 1 2 3 4 5 22) My baby being fed by an intravenous line or tube NA 1 2 3 4 5 23) When my baby seemed to be in pain NA 1 2 3 4 5 24) When my baby looked sad NA 1 2 3 4 5 25) The limp and weak appearance of my baby N A 1 2 3 4 5 26) Jerky or restless movements of my baby NA 1 2 3 4 5 27) My baby not being able to cry like other babies NA 1 2 3 4 5 28) My baby crying for long periods NA 1 2 3 4 5 29) When my baby looked afraid NA 1 2 3 4 5

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128 30) Seeing my baby suddenly change color (for example, becoming pale or blue) NA 1 2 3 4 5 31) Seeing my baby stop breathing NA 1 2 3 4 5 The last area we want to ask you about is how you fe el about your own RELATIONSHIP with the baby and your PARENTAL ROLE. If you have experienced the following situations or feelings, indicate how stressful you have been by them by circling the appropriate number. Again, circle NA if you did not experience the item. 32) Being separated from my baby NA 1 2 3 4 5 33) Not feeding my baby myself NA 1 2 3 4 5 34) Not being able to care for my baby myself (for example, diapering, bathing) NA 1 2 3 4 5 35) Not being abl e to hold my baby when I want NA 1 2 3 4 5 36) Feeling helpless and unable to protect my baby from pain and painful procedures NA 1 2 3 4 5 37) Feeling helpless about how to help my baby during this time NA 1 2 3 4 5 38) Not having time to be alone with my baby NA 1 2 3 4 5 39) Sometimes forgetting what my baby looks like NA 1 2 3 4 5 40) Not being able to share my baby with other family members NA 1 2 3 4 5 41) Being afrai d of touching or holding my baby NA 1 2 3 4 5 42) Feeling staff is closer to my baby than I am NA 1 2 3 4 5 Using the same rating scale, indicate how stressful in general, the experience of having your baby hospitalized in the NIC U has been for you (circle one): 1 = Not at all stressful: the NICU experience did not cause me to feel upset, tense, or anxious 2 = A little stressful 3 = Moderately stressful 4 = Very stressful 5 = Extremely stressful: the NICU experience upset me a nd caused a lot of anxiety or tension Thank you for your help. Now, was there anything else that was stressful for you during the time that your baby has been in the neonatal intensive care unit? Please discuss below: ___________________________________ _________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ _______________________________________ _____________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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129 PART 4 : Background Information For que stions 43 52 please select or insert the most appropriate answer. 43 ) How old were you on your last birthday? ______ years 44 ) What is your marital status? Single/Never Married Married Divorced/Separated Widow 45 ) How many years of school have you completed? Grade 1 8 Some high school High school graduate Some vocational/technical school Vocational/technical graduate Some college College graduate Graduate or professional degree 46 ) Are you employed? yes no If YES, what is your current occupation? (job title) __________________________________ 47 ) What is your combined family income in 2010? Less than $20,000 $20,000 $40,000 $40,000 $60,000 $60,000 $80,000 $80,000 $1 00,000 More than $100,000 48 ) What country are you originally from? ________________________________________ 49 ) What is your ethnicity? White Black Hispanic Asian Other 50 ) Do you consider yourself an: Extrovert Introvert 51 ) Do you have other children? yes no 52 ) Have you previously expressed milk or breastfed another child? yes no PART 5: Volunteer Interview Would you be willing to participate in an interview with the principal researcher and provid e information about the environmental privacy you have experienced in the NICU? yes no

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130 LIST OF REFERENCES Aiello, J. R., & Baum, A. (1979). Residential crowding and design New York: Plenum Press. Altimier, L. B. (2004). Healing e nvironments : For p atients and p roviders. Newborn and Infant Nursing Reviews, 4(2), 89 92. Altman, I. (1975). The environment and social behavior: Privacy, personal space, territory, crowding. Monterey, CA: Brooks Cole Publishers. American Academy of Pediatrics, Work Group on Breastfeeding. (2005). Breastfeeding and the use of human milk. Pediatrics, 115(2), 496 506. Architectural Analysis. (2011). Retrieved on October 14, 2011, from http://www.upedu.org/process/activity/ac_arcan.htm Baumeister, R. F. & Bushman, B. J. (2008) Social psychology and human nature. Belmont, CA: Wadsworth Publishing. Best Evidence Statement. (2011). Retrieved on November 25, 2011, from http://www.cincinnatichildrens.org/service/j/anderson center/evidence based care/bests/ Breastfeeding. (201 1). Retrieved on November 26, 2011, from http://www.cdc.gov/breastfeeding/data/reportcard.htm Brown, P., & Taquino, L. T. (2001). Designing and delivering neonatal care in single rooms. Journal of Perinatal & Neonatal Nursing, 15(1) 68 83. Browne, J. V. (2004). Early relationship environments: Physiology of skin to skin contact for parents and their preterm infants. Clinics in Perinatology, 31 287 298. Burde n, B. (1998). Privacy or help? T he use of curtain positioning strategies within the maternity war d environment as a means of achieving and maintaining privacy, or as a form of signaling to peers and professionals in an attempt to seek information or support. Journal of Advanced Nursing, 27(1), 15 23. Carter, B. S., Carter A., & Bennett, S. ( 2008). Fa private room. Journal of Perinatology, 28, 827 829. Carter, J. C., Mulder, R. T., & Darlow, B. A. (2007). Parental stress in the NICU: The i nfluence of personality, psychological, pregnancy and family factors. Personality and Mental Health, 1, 40 50.

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131 Colaizy, T. T. & Morriss, F. H. (2008). Positive effect of NICU admission on breastfeeding of preterm US infants in 2000 to 2003. Journal of Per inatology, 28(7), 505 510. Cooper, L. G., Gooding, J. S., Gallagher, J., Sternesky, L., Ledsky, R., & Berns, S. D. (2007). Impact of a family centered care initiative on NICU care, staff and families. Journal of Perinatology, 27, S32 S37. Devlin, A. S., & Arneill, A. B. (2003). Health care environments and patient outcomes: A review of the literature. Environment and Behavior, 5, 665 694. Domanico, R., Davis, D. K., Coleman, F., & Davis Jr., B. O. (2010). Documenting the NICU design dilemma: Parent and staf f perceptions of open ward versus single family room units. Journal of Perinatology, 30, 343 351. Dudek Shriber, L. (2004). Parent s tress in the n eonat al intensive care unit and the i nfluence of p arent and i nfant c haracteristics. The American Journal of Oc cupational Therapy, 58(5), 509 520. Evans, G. W., Maxwell, L. E., & Hart, B. (1999). Parental language and verbal responsiveness to children in crowded homes. Developmental Psychology, 35, 1020 1023. Evans, G. ork: the role of architecture in human health. Journal of Environmental Psychology, 18, 85 89. Evans, J. B. & Philbin, M. K. (2000). The acoustic environment of hospital nurseries: Facility and operations planning for quiet hospital nurseries. Journal of Perinatology, 20, S105 S112. Fontes Pinto Novaes, M. A., Knobel, E., Bork, A. M., Pav o, O. F., Nogueira Martins L. A., & Bosi Ferraz, M. ( 1999 ). Stressors in ICU: perception patient, relatives and health care team. Intensive Care Medicine, 25, 1421 1426. Forcada Guex, M., Pierrehumbert, B., Borghini, A., Moessinger, A. & Muller Nix, C. (2006). Early d yadic p atterns of m other i nfant interactions and o utcomes of p rematurity at 18 m onths. Pediatrics, 118(1), e107 e114. Fournier, M. A. (1999). Impact of a f amily centered care approach on the design of neonatal intensive care units (Doctoral dissertation, Texas A&M University ) Retrieved from Dissertations & Theses: Full Text. (Publication No. AAT 9943483). Furman L. & Kennell J. (2000). Breastmilk and ski n to skin kangaroo care for premature infants: Avoiding bonding failure. Acta Paediatrica, 89(11), 1280 3. Furman, L., Minich, N., & Hack, M. (2002). Correlates of lactation in mothers of very low birth weight infants. Pediatrics, 109(4), e57.

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137 BIOGRAPHICAL SKETCH Jeannette Marie P rice was born in Alexandria, Virginia, but moved to Florida when she was very young. She was raised in the town of Orange Park, a bedroom community just outside of Jacksonville. Throughout her life she has enjoyed a myriad of creative activities such as dancing, singing, playing an instrument and photography. When introduced to the field of interior design in 2004, she imagine d herself doing nothing else. While working towards her undergraduate degree in interior design, Jeannette interned at Ginny Stine Interiors and Catlin Design, as well as held the position of Materials Librarian for the Department of Interior Design. She receiv ed her Bachelor of Design in i n terior d esign from the University of Florida in the spring of 2009 graduating summa cum laude and immediately began pursuing her graduate degree with a focus o n the design of healthcare environments. degree Jeannette cont inued her internship at Catlin Design and held the position of Editorial Assistant for the Journal of Interior Design. In the summer of 2010, she studied abroad in Vicenza, Italy at Vicenza Institute of Architecture where she visited the Spedale degli Inno centi, Foundling Hospital in Florence Subsequently, Jeannette graduated in the fall of 2011, receiving her Master of Interior Design degree from the University of Florida