Background
Methods
Study design, research sites and participant recruitment
Data collection and analysis
Participants
Characteristic | N |
---|---|
Professions: | |
Midwives (i.e. Students = 3; Banda 5 = 1; Band 6 = 5; Band 7 = 7) | 16 |
Maternity care assistants | 2 |
Neonatal nurses (i.e. Band 5 = 4; Band 6 = 5; Band 7 = 3) | 12 |
Doctors (i.e. consultant obstetrician; junior registrar) | 2 |
Chaplain | 1 |
Working at: | |
CDS | 21 |
NICU | 12 |
Research Site (RS) | |
RS I | 9 |
RS II | 13 |
RS III | 11 |
Gender | |
Female | 33 |
Male | 0 |
Had used the cold cot: | |
Yes | 7 |
No | 26 |
Results
A. Perceived benefits of using a cold cot
Staff were clearly able to identify and appreciate the main function of cold cot and some had had the opportunity to observe the outcome of body preservation in practice. Yet, the point at which the technology gained its perceived significance was when staff linked its use to affording time. Cold cots were the technological means through which precious time was provided to parents to mourn the loss of their child and have some degree of control over the grieving process. Several participants thought that being able to spend time with the baby was extremely important for parents as it supported them in coming to terms with the situation at their own pace, without the time constraints associated with the physical processes of body deterioration. Cold cots also provided a space for parents to connect with their baby, develop a bond and experience themselves as a family unit with the baby. This was indeed contrasted with common practices of the past when babies were taken away rapidly after delivery and parents did not have the chance to experience feelings of connection, loss and grief. The cold cot connoted a recognition of all these feelings experienced by parents in cases of perinatal mortality whilst the distressing event of the loss was seen to acquire the right level of importance.I think that the fact that the baby doesn’t change colour so rapidly is very special, I mean I’ve seen parents where they have chosen not to use a cold cot and you can be in a very warm room for about 3 hours and actually the baby can change colour very very rapidly apart from the aroma as well and actually you don’t want that either so a cold cot is brilliant, it really is. (P23, RS III, CDS)
I suppose it helps with the grieving process because departing would be when they were, they would probably never be ready, but when they could break away rather than be broken away to say goodbye. (P04, RS I, CDS)
B. Scenarios of technology use
Having judged that the use of a cold cot would be relevant, staff then articulated a series of scenarios in which the deployment of technology was thought to be markedly useful. Such scenarios included situations where the death of the baby was unexpected and when parents had difficulty to separate themselves from the baby and say their goodbyes.Having the cold cot available for the ladies who are here longer is just, enhances their care I think, you know it’s not for everybody as I say some people almost want to dash out the door a couple of hours after delivery. (P17, RS II, CDS)
A further scenario was when mothers were medically unwell and could not hold their baby but still wanted their baby staying with them in the room during mothers’ recovery time. Although participants expressed the opinion that the cold cot could in principle be used with babies of any gestation, as long as parents wished to spend time with them, it was perceived to be even more useful and relevant with babies of later gestations (e.g., term babies) and neonates. The main reason for this was staff’s perception that it is parents of babies nearing term and neonates that are more likely to want to stay with their baby after loss. In cases of older babies, extended family were also more likely to be willing to visit and see the baby. Preserving the baby in good condition, especially when siblings were brought in – often young children themselves – was thus important. Although staff did not exclude the possibility of using a cold cot with babies of earlier gestations, size-related concerns were expressed by two participants, in that the big size of a cold cot compared to that of the baby would not create a sense of ‘nurturing’ environment. As a participant characteristically said, “the cold cot would have been a huge great big fridge” (P01, RS I, CDS); for small babies, staff used special sized Moses baskets.I think for the mums who can’t quite let the baby go that’s when a cold cot comes in really. (P26, RS III, CDS)
A few participants also suggested that using a cold cot would be useful in cases of post-mortem examination. Although doing a post-mortem examination was not common in the neonatal unit, in cases of unexplained intra-uterine death (IUD) where parents might want to find out the cause of death and also spend time with their baby, the technology was deemed useful. Nevertheless, concerns were occasionally expressed as to whether the use of a cold cot in cases of post-mortem examination would be appropriate in terms of body preservation compared to the routine practice of keeping the baby in the mortuary.I think maybe for sort of those babies that are a bit bigger I think it might be useful to use definitely because I think not only do the parents obviously want a cuddle as well but grandparents want to come in don’t they and have cuddles. (P12, RS II, CDS)
Two participants expressed the idea that the cold cot could be used with babies in the absence of parents if parents did not want their baby to go to the mortuary for some length of time. The technology was envisioned to replace the function of mortuary, that is, to preserve the body, but the baby would not be physically separated and would remain in the medical unit. Yet, one participant questioned whether having a dead baby placed in a cold cot in a room without the parents being present would be appropriate as it would feel like the baby was abandoned and it might also present challenges for staff who happen to enter that room and encounter a dead body.I guess some of the nurses sometimes just worry that it’s such a hot unit and even though the cold cot is a cold cot I guess you may be worried that will the baby start to decompose slightly or would they be a bit too warm in the outside environment even though they’re lying in a cold cot. (P27, RS III, NICU)
The work of the staff in the neonatal unit sometimes included an element of palliative care as babies with life-limiting conditions were often being cared for in this environment. One participant mentioned that the cold cot could be used when parents of babies with a life-limiting condition preferred their child to die at home.How do we manage the situation of not a nurse being there but the family being able to confidently use that equipment? (P18, RS II, NICU)
C. Introduction of the technology to parents
A few participants who had used the cold cot reported that they took the chance to introduce the technology when parents noticed and brought up the issue of body deterioration (i.e., change of colour; stiffness of body). However, one posed the question as to whether the technology should best be suggested when the body starts deteriorating or before that since this participant perceived that the use of a cold cot aimed to prevent deterioration. Others preferred to introduce the technology by focusing on and explaining what it does and how parents are assisted to stay longer with their baby without going into much discussion about the sensitive, and potentially distressing, topic of body deterioration. This facilitated for some a more straightforward introduction that concentrated on the function and purpose of cold cots. Informing parents that the baby’s body will get very cold was for some a necessary and important part of the introduction so that parents anticipate and get prepared for that.There is never a definite right or wrong thing to say you’re kind of led by the family you’re looking after and you know I think you find your words sometimes as it happens as the situation is in front of you. (P24, RS III, CDS)
Finally, one neonatal nurse found that it is appropriate to introduce the technology when she was having discussions with parents about the special room the unit had available for bereaved parents. Although most participants expressed some degree of concern around introducing the technology timely, sensitively and appropriately, one believed that if cold cots were already set up in the clinical setting and had been progressively embedded into the practices of care and routinized – as it is the case with other pieces of medical equipment – its introduction to parents should not pose major challenges and parents would be accepting.I think the main important thing to tell parents is the fact that obviously if we do use the cold cot the baby is going to be very cold because I think even if you prepare parents the best you can, that’s my only worry about the cold cot is that the shock to parents of how cold the baby will be and whether that, you know the impact that might have on the parents. (P19, RS II, NICU)
But could it not just be the norm? I mean I can’t, you know, we put the babies in baskets anyhow so why can’t we put them in cold cots and I, to be honest I don’t think you would be involved in a lot of difficult conversations with parents about because I just don’t actually think the parents are really at, that’s not what’s bothering them at the time, is it? (P08, RS I, CDS)
D. Concerns around using and naming the technology
Participants’ concern around the coldness of the baby was further reflected on the nomenclature of the technology. Several interviewees thought that the term ‘cold cot’ is not attractive and might discourage parents from using the technology as they might get scared at the sound of it. Some even suggested that the name ‘cold cot’ is paradoxical since cots are typically associated with warmth – not with coldness – and are supposed to be an environment that keeps the babies warm. A few participants suggested, and sometimes used, alternative names for the technology such as ‘cooling mattress’, ‘cosy cot’, or ‘special cot’, and preferred to introduce the technology to parents by explaining and talking about how it can help and how it works. Moreover, a few reflected on the possibility of using the term ‘cuddle cot’ that is suggested by the manufacturer of a specific model. Although the name ‘cuddle cot’ was considered more attractive and encouraging, staff were concerned about it being misleading and not representing the reality of the technology. Since participants thought that one of their primary duties is to be honest, yet gentle, with parents and not induce any confusion or misunderstanding, they exhibited considerable creativity in naming the technology in alternative ways that did not sound discouraging but still portrayed the technology.I think the thing for me was that a baby when it’s born is warm and you cuddle a baby to keep it warm and that’s your nurturing instinct and you don’t want the baby to get cold and what happens with still born babies obviously is they, they get cold because there's nothing but then so your instinct is that you want to keep them warm and what we're doing with cold cots is actually making them cold. And it’s the actual feel, I think it’s true of any dead person, but the feel of a cold baby more so than the look, obviously babies that are dead are blue and pale and don’t look like they are alive, but it’s more the feel of them, the fact that they are icy cold is what really brings home to you that this baby isn't a baby, a normal baby. It’s the stillness and the coldness… (P01, RS I, CDS)
We’re calling it a cosy cot. That’s what we’re calling it […]we’re not using the term cold cot because we don’t want it to sound horrible, it’s supposed to be, to help not to make them scared. (P18, RS II, NICU)
E. Usability aspects
The only problematic aspect that some participants from research sites I and III mentioned was that the technology was quite noisy which seemed to be related to the specific cold cot model available to the unit. Although staff were worried that the noise might be irritating for, and interfere with parents, on occasions the technology had been used the parents did not appear to be annoyed from the noise or pay any special attention to it. Rather, the technology, including its sound, was gradually incorporated into family’s experience of spending time with their baby. Yet, other participants thought that the sound the technology produced when it was being used was very soft and did not create any concerns.We usually get someone in to train us up on, on our equipment so I don’t, I don’t think anybody has come to train us on it…it is a straightforward cot you just kind of plug it in and set it at a certain temperature and there it goes. (P33, RS III, NICU)
I mean, the only thing I will say with using it is the ones we have can be, the motor can be quite loud, overnight. (P07, RS I, CDS)