Running Head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Literature Review

Elizabeth Shook

Bon Secours Memorial College of Nursing

Dr. Arlene Holowaychuk

NUR 4122

April 10th, 2018

“I pledge”
INTEGRATIVE LITERATURE REVIEW 2

Abstract

The purpose of this paper is to quantitatively compare the practice of co-bedding preterm twins

in the Neonatal Intensive Care Unit (NICU) to standard infant care in the NICU (sleeping in

separate bassinettes). There is a higher incidence of multiple gestational births around the world

because of advances in medicine. Hospital NICUs need to implement practices to assist in caring

for twins undergoing painful procedures such as heel lances and provide a comfortable

environment with their sibling, which can help regulate vital signs and neurodevelopment.

Design methods of this integrative review include reviewing five peer-reviewed articles

published in the past five years. Major findings from these five studies concluded that co-

bedding twins could have a decreased pain response, decreased crying time, no increased risk of

adverse events or infection, but minimal difference in physiological responses such as heart rate

or apnea episodes. Limitations of these studies included the inability of the researchers to blind

themselves to the subjects, the difficulty in determining the difference in stress and pain

responses, and the need for further larger studies in co-bedding to solidify the findings. The

limitations of the researcher are inexperience in clinical studies and integrative research reviews.

Implications of the research indicate that co-bedding can have a positive effect on preterm twins

in the NICU and can lead to reduced hospital stays. The author recommends further studies are

needed and that co-bedding should be a practice implemented in the NICU.

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Integrative Literature Review

The purpose of this integrated review is to explore the merits of co-bedding preterm twins

(two twins in one bassinet or incubator) on the stress and physiological responses of the

neonates. Because multiple gestations are becoming more and more common due to advances in

medical technology, this research is important to nursing practice in the NICU for preterm twins

(Legrand et al., 2017). Previous research shows that there might be a physical benefit to co-

bedding twins (Hayward, Johnston, Campbell-Yeo, Price, Houk, Whyte, White, Caddell, 2015).

Because of the safety concerns of co-bedding infants, there is a finite amount of research mostly

done outside the United States. The researcher found many articles in the early twenty-first

century, but there were only a few articles found within the last five years. The researcher has a

personal interest in this topic because of family dynamics and preterm twin cousins who were in

the NICU for three days following birth. This paper will compile literature to support the

researcher’s PICO question, in premature infant multiples (PIM), does co-bedding decrease

hospital stay compared to PIM who are alone in the bassinet or incubator?

Design and Research Methods

The research design for this paper is an integrative review, which looks at five research

articles all dated within the last five calendar years (2013-2018). The databases used for

searching were EBSCO Discovery, PubMed, Google Scholar, and EBSCO Medline Complete.

The keys words used for the search were ‘co-bedding’, ‘cobedding’, ‘NICU’, ‘preterm twins’,

‘stable twins’, and ‘neonatal intensive care unit’, ‘NICU’, ‘preterm infants’, and ‘infants’.

EBSCO Discovery search revealed 22 articles, most of which were published previous to 2013.

EBSCO Medline search revealed two articles which were both older than 2013. Pubmed and
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Google Scholar were both searched and revealed over 100 articles, most of which were repeated

articles and over five years old.

All articles used by the researcher in this integrative review were taken from EBSCO

Discovery search. The search was adjusted for articles between 2013 and 2018 and a subsequent

search revealed eight articles. The search parameters were limited to be in English, were printed

in peer-reviewed journals, as well as relevant to the researcher’s PICO question “in premature

infant multiples (PIM), does co-bedding decrease hospital stay compared to PIM who are alone

in bassinet or incubator?” Articles that did not meet these qualifications were excluded. Most

articles did not have full text on EBSCO Discovery and the full article was located by following

the included hyperlinks. Five articles were selected as the final articles for review.

Findings and Results

The findings and results of the five presented articles shows a positive response to co-

bedding on neonatal stress, physical responses, and hospital stay length (Adams and Gill, 2014;

Badiee, Nassiri, & Armanian, 2014; Campbell-Yeo, Johnston, Joseph, Feeley, Chambers,

Barrington, & Walker 2014; Hayward et al., 2015; Legrand et al., 2017.) A summary of the five

articles is presented in Table 1. The researcher outlined the review using the following

categories: buccal cortisol stress response, physiological responses, and nursing competency of

co-bedding practice and safety.

Buccal Cortisol Stress Response

Two quantitative articles of randomized control studies measured the buccal cortisol

levels after a heel lance in co-bedded versus standard care twins to assess their stress levels and

concluded that co-bedded twins had less stress 20 minutes after a heel lance than standard care

twins (Badiee et al., 2014 & Campbell-Yeo et al., 2014). In the randomized control study
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performed by Badiee et al. (2014) 105 infants split into co-bedding and standard care groups

were evaluated for buccal salivary cortisol levels one minute prior to and 20 minutes after a heel

lance to objectively measure their stress level. Cortisol is a hormone released in response to

perceived stress and pain. The infant sample consisted of medically stable preterm infant twins

that required a medical heel lance procedure. The variable was a salivary cortisol level one

minute prior and 20 minutes after the heel lance, obtained by a buccal swab. The pain scale was

also obtained using a Premature Infant Pain Profile (PIPP). Data was analyzed by using SPSS

software version 18. The statistically significant findings included the Premature Infant Pain

Profile (PIPP) had a score 1.7 points lower in the co-bedding group than the standard care group,

20% of standard care infant had a severe pain PIPP score of 12 and 6% of the co-bedded group

had a severe pain PIPP score of 12, salivary cortisol levels were lower at the 20 minute mark in

the co-bedding group, and crying duration was shorter in the co-bedding group.

Similarly, the quantitative, randomized control trial conducted by Campbell et al. (2014)

researched the salivary cortisol levels of preterm infants as well. The researchers were trying to

determine if co-bedding was an adequate intervention for pain and stress management in preterm

infant twins. The sample size for this study was 67 sets of preterm twins born between 28 and 36

gestational weeks that were medically stable and requiring a medically necessary heel lance. The

variable that was studied was the salivary cortisol levels obtained one minute before and 20

minutes after the heel lance, obtained by buccal swab. The data was analyzed using SPSS 17,

and the means of the cortisol levels were compared between co-bedding and non-co-bedding

groups. The statistically significant findings were that prior to the heel lance there was no

significant difference in the cortisol levels of the co-bedding and standard care groups. However,

20 minutes after the heel lance, the co-bedding group had significantly lower cortisol levels.
INTEGRATIVE LITERATURE REVIEW 6

These results are consistent with the researchers hypothesis that co-bedding can reduce the pain

response and stress in preterm infant twins.

Physiological Responses

Two studies examined the physiological responses of the newborn co-bedding twins and

theorized that the response would include more stable vitals signs and co-regulation, better sleep

patterns, and quicker birth-weight recovery (Hayward et al., 2015; Legrand et al., 2017). In the

monocentric prospective randomized control trial performed by Legrand et al. (2017) the

researchers were trying to determine if co-bedding twins in the NICU led to reduced birth-weight

recovery time, reduced hospitalization, and reduced weaning time. This study consisted of 28 co-

bedded and 32 standard care twins that were between the gestational age of 30-34 weeks, with no

congenital defects and were medical stable, and required intubation or continuous positive

airway pressure (CPAP). The variables that were studied consisted of growth parameters

(weight, length, head circumference), length of stay (LOS), physiological responses (Heart Rate,

Respiratory Rate, temperature, etc.) and neurocognitive development at two years of age. The

tools used to assess the twins in addition to medical heart and vital monitors were the Reversed

Amiel-Tison Comfort Scale, Ages and Stages Questionnaire-Third Edition, and Loire Infant

Follow-Up Team. The data was analyzed with SPSS version 16.0. The statistically significant

findings concluded that the daily weight gain between the co-bedded and standard care groups

was not significantly different but the birth-weight recovery time in the co-bedding group was

shorter. The researchers also concluded that the physical responses such as heart rate etc. were

not different between groups and even that the co-bedding group experienced more incidence of

tachycardia; the two year follow-up also did not reveal any significant neurodevelopmental

differences between the co-bedded and standard care groups.

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The study performed by Hayward et al. (2015) similarly explored the notion that co-

bedding twins could provide twins an opportunity to reduces stress and co-regulate their physical

responses and sleep patterns, and cope in the extra-uterine environment together. This study’s

sample consisted of 117 sets of medically stable twins born before 37 weeks gestation. The

variables studied were sleep/wake cycles, and co-regulation and physiological regulation. The

data was collected by video sleep/wake cycles for three hours on day of admission, day 3, and

day 7, and by obtaining vital signs and comparing them to the standard care group. The tools that

were used to obtain data about the studied variable were video cameras and medical monitor

equipment. The data was analyzed using RM-MANOVA, GEE. The statistically significant

findings concluded that there were no significant difference in adverse events between groups.

Co-bedded twins spent more time in the same physiological state than standard care twins, and

more time in quiet sleep than standard care.

Nursing Competency of Co-Bedding Practice and Safety

Safety of the premature multiples and nurse competency are important factors in the

treatment plans in the NICU, as adverse events can lead to declining health and longer hospital

stays. Four studies addressed safety of co-bedding twins (Badiee et al., 2014; Campbell-Yeo et

al., 2014; Hayward et al., 2015; and Legrand et al., 2017). Overall, they reported that co-bedding

showed no increased rate of adverse events such as medication errors or infection rates than

standard care. Hayward et al. (2015) reported no adverse events in their co-bedding subjects.

One study looked at the competencies of nurses utilizing co-bedding in the NICU by Adams and

Gill (2014). The purpose of this study was to determine the level of knowledge and competency

of nurses and midwives in co-bedding twins in the NICU as well as their opinions on the co-

bedding practice. One-hundred and forty-eight out of two-hundred and one nurses and midwives
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with a wide range of years of experiences and ages were given a 25 question survey to test they

knowledge and opinions on co-bedding. The type of data collected included multiple choice and

ranking (1-5) questions. The methods of collecting data included personally handing out surveys

in the NICU and the data was analyzed using a 2010 Microsoft Excel program. The statistically

significant findings included a 94% rate of correctly answering questions on co-bedding and a

74% rate of positive views and opinions on co-bedding. The most common answer to the merits

of co-bedding was the opinion that physical contact or skin-to-skin contact between twins can

lead to positive outcomes.

Discussion and Implications

The five articles that were chosen for this review discussed the merits of co-bedding

premature twins in the NICU. These articles reviewed the factors that can contribute to shorter

hospital stays such as reduced stress, better pain management, improved physical responses, and

safety. The randomized control study performed by Campbell-Yeo et al. (2014) looked at the

stress responses in NICU twins by measuring the salivary cortisol levels at a painful procedure

such as a heel lance. Their results showed that co-bedding twins can lead to less stress, decreased

crying times, and lower cortisol levels. The study by Badiee et al. (2013) deduced a similar

conclusion, that co-bedded twins had lower salivary cortisol levels after a heel lance and

therefore less stress in the NICU. They also concluded that co-bedding twins had fewer

incidences of severe pain score of 12 on the Premature Infant Pain Profile (PIPP) scale. The

studies by Legrand et al. (2017) and Hayward et al. (2015) looked at the physical responses such

as vital signs, growth parameters, sleep cycles and neurodevelopment of co-bedding versus

standard care twins. Legrand et al. (2017), a monocentric prospective randomized control study

researched the growth parameters, vitals signs, and length of hospital stay of co-bedding twins
INTEGRATIVE LITERATURE REVIEW 9

and determined that the co-bedding twin group had faster birth weight recovery that the standard

care group although there was little difference in the vitals sign trends or the two year follow-up

neurodevelopment. Hayward et al. (2015) looked at the sleep cycles, safety concerns, and

physical regulation and concluded that co-bedding can have positive effects on these variables.

These articles relate to the researcher’s PICO question by addressing the idea that co-bedding

can lead to shorter hospital stays. The majority of the research focused on stress and

physiological responses to the treatment performed in the NICU. Less stress and better co-

regulation of physical responses can lead to faster growth, weight gain, and recovery from birth,

which results in a shorter length of stay. In addition, safety is a concern when it comes to hospital

stay as an adverse event such as medication error, infection, or apnea episode can be detrimental

to the health of the neonates and can result in a longer hospital stay.

Each of these articles discusses implications for nursing practice protocol. In co-bedding

there are safety concerns and a Sudden Infant Death Syndrome (SIDS) risk. All of these articles

mentioned that co-bedded twins were properly identified and that any risk is minimal. There

were also minimal differences in infection rates between co-bedding and standard care groups

(Hayward et al., 2015). The researcher of this integrative review also takes into consideration

that newborn infants are developmental immature and unable to roll over into an unsafe position,

they are constantly on vital sign monitors, and are watched constantly by nursing staff. In

addition, according to Adams and Gill (2015) nurses in the NICU unit are well educated on

premature infants and are aware of co-bedding protocol safety. The studies of Legrand et al.,

(2017) and Hayward et al. (2015) stated that they were some of the first research studies to look

at both neurodevelopment and physical regulation, therefore there needs to be continuing studies

in this field especially since they determined that co-bedding twins in the NICU has merit. Future
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studies could possible include comparing co-bedding twins, to standard care twins, and singleton

neonates to further explore the merits of co-bedding and if it has a deeper benefit than was

shown in these articles.

Limitations

This integrative review has limitations in the quality of the review. This is a first time

integrative review, conducted as a class assignment for a Bachelor’s of Science in Nursing

(BSN) program by an inexperienced student enrolled in the program full time. There were only

five articles reviewed and they were only from the past five years, therefore there is not a wide

and diverse range of studies and information to draw from. Most research on co-bedding twins in

the NICU appears to have been conducted in the late 1990s and early 2000s. There is limited

clinical practice experience from the student researcher and it influences the comprehension of

the research.

The limitations of the research articles include not being able to blind the staff and

researchers to the subjects (Badiee et al., 2103; Hayward et al., 2015). Also the study conducted

by Campbell-Yeo et al. (2014) stated that another limitation was that they could not differentiate

between pain and stress. All studies stated that adequate sample size for their respective studies

were maintained and attrition rate was low; however, further research needs to be conducted on

these variables such as pain responses and neurodevelopment, as these studies were the first of

their kind to the authors knowledge.

Conclusion

The findings of this integrative review conclude that there are merits to co-bedding

preterm twins in the NICU. Co-bedding can result in less stress, decreased pain response, and

better regulation of physical responses such as vital signs. These responses can lead to shorter
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hospital stays and better outcomes for co-bedding twins. While safety and infection is a concern

in all areas of the hospital, there was minimal evidence to support that co-bedding in the NICU

can increase the infants’ risk of these complications. Co-bedding could be important to nursing

practice, because if nurses can implement evidence-based practices to decrease stress and pain in

newborn twins, hospital stays might decrease. This integrative review concluded that co-bedding

is beneficial to the healing and development of preterm twins as opposed to standard care, which

is in line with the researcher’s PICO question.

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References

Adams, C., & Gill, F. J. (2014). Co-bedding of multiples in the neonatal unit: Assessing nurses

and midwives attitude and level of understanding. Journal of Neonatal Nursing, 20(2),

82-88. doi:10.1016/j.jnn.2013.07.002

Badiee, Z., Nassiri, Z., & Armanian, A. (2014). Cobedding of twin premature infants: calming

effects on pain responses. Pediatrics And Neonatology, 55(4), p 262-268.

doi:10.1016/j.pedneo.2013.11.008

Campbell-Yeo, M. L., Johnston, C. C., Joseph, K. S., Feeley, N., Chambers, C. T., Barrington,

K. J., & Walker, C. (2014). Co-bedding between preterm twins attenuates stress response

after heel lance: results of a randomized trial. The Clinical Journal of Pain, 30(7), 598-

604. doi:10.1097/AJP.0000000000000015

Hayward, K. M., Johnston, C. C., Campbell-Yeo, M. L., Price, S. L., Houk, S. L., Whyte, R. K.,

& ... Caddell, K. E. (2015). Effect of cobedding twins on coregulation, infant state, and

twin safety. Journal of Obstetric, Gynecologic, and Neonatal Nursing: JOGNN, 44(2),

193-202. doi:10.1111/1552-6909.12557

Legrand, A., Frondas, A., Aubret, F., Corre, A., Flamant, C., Simon, L., & ... Rozé, J. (2017).

Randomised controlled trial shows that co-bedding twins may reduce birthweight

recovery delay, parenteral nutrition weaning time and hospitalisation. Acta

Paediatrica, 106(12), 2055-2059. doi:10.1111/apa.13885

INTEGRATIVE LITERATURE REVIEW 13

Table 1: Qualitative and Quantitative Article Evaluation

Reference (APA) Campbell-Yeo, M. L., Johnston, C. C., Joseph, K. S., Feeley, N.,
Chambers, C. T., Barrington, K. J., & Walker, C. (2014). Co-bedding
between preterm twins attenuates stress response after heel lance: results of
a randomized trial. The Clinical Journal Of Pain, 30(7), 598-604.
doi:10.1097/AJP.0000000000000015
Author Campbell-Yeo (2014) PhD, RN, Department of Pediatrics, School of
(Year)/Qualifications Nursing, Dalhousie University
Introduction/ This article focused on examining the effect of co-bedding preterm twins
Background/Problem on pain and stress response after a heel lance. Co-bedding is defined as
Statement
twins staying and being treated together in one incubator. Researchers are
trying to prove there are positive attributes to co-bedding
Conceptual/ Researchers want to study the effect of co-bedding on the pain and stress
Theoretical response to a heel lance
Framework

Design/Research -Quantitative, Randomized control trial, received REB and Institutional

Methods/Sample/
Setting/Ethical Ethics Board approval in 3 Level III and IV university affiliated sites in
Considerations/ Canada
Major Variable Studied/ -Sample: 67 sets medically stable preterm twins between 28 and 36 weeks
Measurement Tool/Data
Collection Tool/Data gestation requiring at least 1 heel lance, setting was in the NICU in Canada
Analysis - Variable: cortisol levels obtained from buccal salivary samples 1 min
before and 20 min after heel lance
-Data was analyzed using SPSS 17. The means of the cortisol levels were
compared between co-bedding and non-co-bedding groups

Findings/Results Cortisol levels were not significantly different between groups at prior to
heel lance but were lower at 20min for co-bedding group
Discussion/ Co-bedding twins suggests that there could be less stress related to NICU
Implications care, and a quicker return to physical baseline after heel lance. This is
similar to studies about skin-to-skin and stress response
Limitations/ Preterm infant circadian rhythm regulation is questionable and most
Conclusions samples were morning samples, it is impossible to determine the difference
in stress and pain response related to cortisol levels
Appraisal/Worth to This is worthy of NICU practice and to PICO question but further research
practice is needed into this subject
INTEGRATIVE LITERATURE REVIEW 14

Reference (APA) Badiee, Z., Nassiri, Z., & Armanian, A. (2014). Cobedding of Twin
Premature Infants: Calming Effects on Pain Responses. Pediatrics And
Neonatology, Vol 55, Iss 4, Pp 262-268 (2014), (4), 262.
doi:10.1016/j.pedneo.2013.11.008
Author Badiee (2013) The only qualification noted was employment through the
(Year)/Qualifications Department of Pediatrics School of Medicine, Isfahan University of
Medical Sciences, Iran
Introduction/ There is a higher incidence of multiple births and NICU admission.
Background/Problem Inadequate pain management can lead to developmental and pain response
Statement
issues. Co-bedding which simulated the uterine environment can reduce
stress and regulate physiological responses
Conceptual/ Randomized trial using salivary cortisol levels and Premature Infant Pain
Theoretical Profile
Framework

Design/Research Needed a sample size of 44 infants and 105 were included in the study,
Methods/Sample/
Setting/Ethical
exclusion was determined from parental refusal, no need for heel lance, or
Considerations/ unstable medical condition
Major Variable Studied/ Ethics board of Isfahan University of Medical Sciences gave approval and
Measurement Tool/Data
Collection Tool/Data consent obtained from parents. The two major variables were the salivary
Analysis cortisol levels 1 min prior and 20 after heel lance and the PIPP
measurement tool measured between co-bedded and standard care twins,
obtained data was analyzed using SPSS software version 18.
Findings/Results PIPP score was 1.7 lower in the co-bedding group suggesting less pain
response, 20% of standard care and 6% co-bedding saw severe pain score
of 12. Crying duration was shorter in co-bedded group and cortisol levels
20min after heel lance was lower in co-bedding group
Discussion/ Co-bedding twins showed a better pain management than separated twins
Implications and severe pain (PIPP of 12) was less in the co-bedding group, co-bedding
is similar to skin-to-skin contact and comfort
Limitations/ Because of the small sample size, infection rates could not be determined
Conclusions Co-bedding could reduce stress and pain response in infant twins and
shorten hospital stay
Appraisal/Worth to This article is worthy of the NICU practice and to the PICO question
practice
INTEGRATIVE LITERATURE REVIEW 15

Reference (APA) Legrand, A., Frondas, A., Aubret, F., Corre, A., Flamant, C., Simon, L., &
... Rozé, J. (2017). Randomised controlled trial shows that co-bedding
twins may reduce birthweight recovery delay, parenteral nutrition weaning
time and hospitalisation. Acta Paediatrica, 106(12), 2055-2059.
doi:10.1111/apa.13885
Author Legrand (2017) Employed at the Women’s and Children’s Clinical
(Year)/Qualifications Investigation Center Nantes, France
Introduction/ The number of multiple gestation pregnancies has been increasing. There
Background/Problem are social bonds in utero between twins and co-bedding tries to continue
Statement
that environment between twins. Utilizing co-bedding will reduce birth-
weight recovery and weaning time and hospitalization
Conceptual/ Co-regulation and synactive theories: the goal is provide developmental
Theoretical and health benefits to twins
Framework

Design/Research -Monocentric prospective randomized control trial, sample size: 28 co-

Methods/Sample/ bedded, 32 separated, between 30-34 weeks gestation, no congenital
Setting/Ethical
Considerations/
pathology, but needed intubation or CPAP
Major Variable -Approved by the Medical Ethics Committee of Nantes, France
Studied/ -Variables: growth parameters (weight, length, head circumference),
Measurement Length of Stay, physiological responses (HR, RR, temp, etc.),
Tool/Data Collection -Tools: Reversed Amiel-Tison Comfort Scale, Ages and Stages
Tool/Data Analysis
Questionnaire-Third Edition, Loire Infant Follow-Up Team
- Analyzed with SPSS version 16.0
Findings/Results -Daily weight gain not different but birth-weight recovery shorter in co-
bedding, physiology: not significantly different, more tachycardia in co-
bedding group
Discussion/ -co-bedding can lead to reduced hospital stay and reduced birth-weight
Implications recovery time, as well as increased orality maturation such as breast
feeding and sucking, and cerebral maturation
Limitations/ - Oral maturation such be taken with caution because there was no
Conclusions nutrition assessments, larger studies are needed to determine results
validity
Appraisal/Worth to - Co-bedding has potential worth to practice, nurses could advocate for co-
practice bedding in NICU units
INTEGRATIVE LITERATURE REVIEW 16

Reference (APA) Hayward, K. M., Johnston, C. C., Campbell-Yeo, M. L., Price, S. L., Houk,
S. L., Whyte, R. K., & ... Caddell, K. E. (2015). Effect of cobedding twins
on coregulation, infant state, and twin safety. Journal Of Obstetric,
Gynecologic, And Neonatal Nursing: JOGNN, 44(2), 193-202.
doi:10.1111/1552-6909.12557
Author Hayward (2015) School of Nursing, Dalhousie University, no other
(Year)/Qualifications qualifications noted
Introduction/ Co-bedding provides an opportunity for twins to cope with the extra
Background/Problem uterine environment. Twins in utero demonstrate co-regulation of
Statement
physiological responses and co-bedding has potential to help with neonatal
co-regulation and stable sleep/wake patterns
Conceptual/ The theoretical framework is the synactive theory of development, three
Theoretical hypotheses noted: 1. Co-bedding will have better co-regulation, 2. Co-
Framework
bedding with better sleep, 3. No increased infection or error
Design/Research -Randomized control trial, sample: 117 sets of twins born before 37 weeks
Methods/Sample/
Setting/Ethical gestation and were medically stable in 2 tertiary level university NICUs,
Considerations/ ethical approval was granted by the Institutional Review Boards of the
Major Variable Studied/ NICUs and parental consent obtained
Measurement Tool/Data
Collection Tool/Data
-Tools: video cameras for sleep/wake cycles, and physiological variables
Analysis -Variables: sleep/wake cycles and co-regulation and physiological
regulation
-Data collection: twins were videoed for 3 hours on admission and day 3
and 7, and vitals obtained
-Data analysis: RM-MANOVA, GEE
Findings/Results Co-bedded twins spent more time in the same physiological state than
standard care twins, co-bedded twins spent more time in quiet sleep and
standard care, no significant difference in adverse events
Discussion/ - There was no significant difference in safety issues and the observed
Implications trends were that co-bedding has a positive effect on co-regulation and
sleep/wake patterns in NICU twins
Limitations/ - Limitations included not being able to blind investigators to the
Conclusions intervention and the decrease in sample size, these positive results will add
to the bank of co-bedding knowledge
Appraisal/Worth to Co-bedding has potential for positive effects on NICU twins and little
practice safety concerns, should be in nursing practice
INTEGRATIVE LITERATURE REVIEW 17

Reference (APA) Adams, C., & Gill, F. J. (2014). Co-bedding of multiples in the neonatal
unit: Assessing nurses and midwives attitude and level of
understanding. Journal Of Neonatal Nursing, 20(2), 82-88.
doi:10.1016/j.jnn.2013.07.002
Author Adams and Gill (2014) Adams is employed through Neonatology Clinical
(Year)/Qualifications Care Unit of King Edward Memorial Hospital and Gill is employed at the
School of Nursing and Midwifery
Introduction/ Premature multiple births are more and more common. Co-bedding is one
Background/Problem developmental strategy being used worldwide based on the notion that it
Statement
can be used to help twins transition from womb to world easier.
Conceptual/ No theoretical framework was identified in this article
Theoretical
Framework

Design/Research -Project design was a twenty-five-item questionnaire. Twenty-one of the

Methods/Sample/
Setting/Ethical
questions were designed to test the knowledge and opinions of the nurses
Considerations/ and midwives of the NICU on the practice of co-bedding.
Major Variable Studied/ -The sample included 148 out of 201 surveys
Measurement Tool/Data
Collection Tool/Data
-Ethics was approved by the Department Nursing Director and the
Analysis University Human Research Ethics Committee
-Variable- nursing knowledge on co-bedding
-Measurement tool was survey, data analysis was done by Microsoft Excel
Spreadsheet 2010
Findings/Results 74% response rate, 94% answered co-bedding questions correctly, 74%
agreed co-bedding had potential benefits, and most agreed that multiples
support through physical contact
Discussion/ High response rate due to local interest in the topic and personally handing
Implications out surveys, sound level of understanding of co-bedding, ¾ agree that co-
bedding has benefit to premature multiples
Limitations/ Did not take into account the other members of the interdisciplinary team,
Conclusions midwives are only 10% of the staff population
Nurses and midwives had a sound understanding of the co-bedding
practice and this has enough support to implement into practice
Appraisal/Worth to Because of the high level of nurse competency, the practice of co-bedding
practice can be a beneficial practice to the NICU unit.