Cummins, A, Coddington, R, Fox, D & Symon, A 2020, 'Exploring the qualities of midwifery-led continuity of care in Australia (MiLCCA) using the quality maternal and newborn care framework.', Women and Birth.View/Download from: UTS OPUS or Publisher's site
PROBLEM:Midwifery-led continuity of care has well documented evidence of benefits for mothers and babies, however uptake of these models by Australian maternity services has been slow. BACKGROUND:It is estimated that only 10% of women have access to midwifery-led continuity of care in Australia. The Quality Maternal Newborn Care (QMNC) Framework has been developed as a way to implement and upscale health systems that meet the needs of childbearing women and their infants. The Framework can be used to explore the qualities of existing maternity services. AIM:We aimed to use the QMNC Framework to explore the qualities of midwifery-led continuity of care in two distinct settings in Australia with recommendations for replication of the model in similar settings. METHODS:Data were collected from services users and service providers via focus groups. Thematic analysis was used to develop initial findings that were then mapped back to the QMNC Framework. FINDINGS:Good quality care was facilitated by Fostering connection, Providing flexibility for women and midwives and Having a sense of choice and control. Barriers to the provision of quality care were: Contested care and Needing more preparation for unexpected outcomes. DISCUSSION:Midwifery-led continuity of carer models shift the power dynamic from a hierarchical one, to one of equality between women and midwives facilitating informed decision making. There are ongoing issues with collaboration between general practice, obstetrics and midwifery. Organisations have a responsibility to address the challenges of contested care and to prepare women for all possible outcomes to ensure women experience the best quality care as described in the framework. CONCLUSION:The QMNC Framework is a useful tool for exploring the facilitators and barriers to the widespread provision of midwifery-led continuity of care.
Symon, A, McFadden, A, White, M, Fraser, K & Cummins, A 2019, 'Using a quality care framework to evaluate user and provider experiences of maternity care: A comparative study.', Midwifery, vol. 73, pp. 17-25.View/Download from: UTS OPUS or Publisher's site
OBJECTIVE:The Quality Maternal and Newborn Care Framework describes the components and characteristics of quality care and emphasises relational and continuity elements. Continuity of care is increasingly a focus of maternity care policy in the United Kingdom. While some outcomes have been shown to be improved, there is uncertainty about why certain models of care are more effective. Our overall objective is to develop a maternity care evaluation toolkit which incorporates this Framework along with other outcome evaluations. An initial step in developing this toolkit was to use the adapted Framework to evaluate perceptions and experiences of maternity care. Our specific objective in this study was to test this adapted Framework in a series of focus groups with key stakeholders, and to compare findings between different groups. Findings related to service users (pregnant women and new mothers) are reported in our accompanying paper; this paper presents findings from focus groups with service providers (midwives and obstetricians), and then compares user and provider perspectives. DESIGN:A qualitative comparative enquiry involving three focus groups with 26 midwives (eight newly qualified; eight working in a community midwifery unit; and ten senior tertiary-based) and two focus groups with twelve obstetricians of all grades. We used a six-phase thematic analysis to derive then compare the focus groups' principal sub-themes; we then mapped these to the original Quality Maternal and Newborn Care Framework and compared these service providers' responses with those from the pregnant women and new mothers. SETTING:Two health boards in Scotland. PARTICIPANTS:Midwives and obstetricians who had experience of various models of maternity care. FINDINGS:There were significant areas of overlap in their perceptions of providing maternity care. All groups reported 'limited resources and time'; the community midwifery unit and senior midwives and one group of obstetricians provid...
Symon, A, McFadden, A, White, M, Fraser, K & Cummins, A 2019, 'Using the Quality Maternal and Newborn Care Framework to evaluate women's experiences of different models of care: A qualitative study.', Midwifery, vol. 73, pp. 26-34.View/Download from: UTS OPUS or Publisher's site
OBJECTIVE:There is evidence that continuity of care - increasingly a focus of maternity care policy in the UK - contributes to improved outcomes. However, uncertainty remains about which models of care are most effective in which circumstances, and why this is. A plausible explanation is grounded in the idea that the continuity elements of care contribute to and reinforce best quality care. The Quality Maternal and Newborn Care Framework describes the components and characteristics of quality care. As a first step in developing a maternity care evaluation toolkit, we adapted this Framework to see if it could be used to evaluate perceptions and experiences of different models of care. DESIGN:A qualitative comparative enquiry using focus groups. From a six-phase thematic analysis, we first derived then compared the principal sub-themes from the focus groups and mapped these to the original Framework. SETTING:Two health boards in Scotland. PARTICIPANTS:Pregnant women, new mothers, midwives and obstetricians who had experience of various models of maternity care. This paper reports findings from the pregnant women and new mothers. RESULTS:These are presented in two parts: the seven focus groups with pregnant women and new mothers are reported in this paper; the five focus groups with midwives and obstetricians in our accompanying paper. Those using the maternity services had experience of caseloading midwifery, 'modified universal provision' and 'high risk' models of maternity care. While women from all groups shared certain perspectives, those with experience of caseloading midwifery were consistently positive, reporting positive relationships, tailored care and effective communication. Women experiencing other models of care, especially the modified universal provision model, tended to report more negative relational experiences: lack of information, lack of tailored care, and anxiety and confusion. Timing of the focus group (i.e. during pregnancy or after the birt...
Symon, A, McFadden, A, White, M, Fraser, K & Cummins, A 2018, 'Adapting the Quality Maternal and Newborn Care (QMNC) Framework to evaluate models of antenatal care: A pilot study.', PloS one, vol. 13, no. 8, pp. e0200640-e0200640.View/Download from: UTS OPUS or Publisher's site
BACKGROUND:Recent evidence indicates that continuity models of maternity care result in improved clinical and psychosocial outcomes, but their causal mechanisms are poorly understood. The recent Lancet Series on Midwifery's Quality Maternal and Newborn Care Framework describes five components of quality care and their associated characteristics. As an initial step in developing this Framework into an evaluation toolkit, we transformed its components and characteristics into a topic guide to assess stakeholder perceptions and experiences of care provided and received. The main purpose of this study was to assess the feasibility of this process. METHODS:We conducted twelve focus groups in two Scottish health board areas with 13 pregnant women, 18 new mothers, 26 midwives and 12 obstetricians who had experience of a range of different models of maternity care. Transcripts were analysed using a six-phase approach of thematic analysis. We mapped the identified themes and sub-themes back to the Framework. RESULTS:The emerging themes and sub-themes demonstrated the feasibility of using the QMNC framework as a data collection tool, and as a lens for analysing the data. Of the four emerging themes, only Organisation Culture / Work Structure' mapped directly to a single Framework component. The others-'Relationships'; 'Information and support'; and 'Uncertainty'-mapped to between two and five components, illustrating the interconnectedness of the Framework's components. Some negative sub-themes mirrored positive Framework characteristics of care. Some re-phrasing and re-ordering of the topic guides in later focus groups ensured we could cover all aspects of the Framework adequately. CONCLUSION:Adapting the Quality Maternal and Newborn Care Framework enabled us to focus on aspects of care which worked well and which didn't work well for these key stakeholders. Identifying 'what works for whom and why' in different models of care is a necessary step in reinforcing and replic...
Symon, A, Rankin, J, Sinclair, H, Butcher, G, Barclay, K, Gordon, R, MacDonald, M & Smith, L 2017, 'Peri-conceptual and mid-pregnancy drinking: A cross-sectional assessment in two Scottish health board areas using a 7-day Retrospective Diary.', Journal of advanced nursing, vol. 73, no. 2, pp. 375-385.View/Download from: UTS OPUS or Publisher's site
To evaluate the use of a 7-day Retrospective Diary to assess peri-conceptual and mid-pregnancy alcohol consumption.Alcohol consumption among women has increased significantly and is of international concern. Heavy episodic ('binge') drinking is commonplace and is associated with unintended pregnancy. Pre-pregnancy drinking is strongly associated with continued drinking in pregnancy. Routine antenatal assessment of alcohol history and current drinking is variable; potentially harmful peri-conceptual drinking may be missed if a woman reports low or no drinking during pregnancy.Cross-sectional study (n=510) in two Scottish health board areas.Face-to-face Retrospective Diary administration from February to June 2015 assessing alcohol consumption in peri-conceptual and mid-pregnancy periods. Women were recruited at the mid-pregnancy ultrasound clinic.Of 510 women, 470 (92.0%) drank alcohol before their pregnancy; 187 (39.9%) drank every week. Retrospective assessment of peri-conceptual consumption identified heavy episodic drinking (more than six units on one occasion) in 52.2% (n=266); 19.6% (n=100) reported drinking more than 14 units per week, mostly at the weekend; 'mixing' of drinks was associated with significantly higher consumption. While consumption tailed off following pregnancy recognition, 5.5% (n=28) still exceeded the recommended daily 2-unit limit in pregnancy. Multivariable logistic regression identified that women who 'binged' peri-conceptually were 3.2 times more likely to do this.Significant peri-conceptual consumption levels suggest a substantial proportion of alcohol-exposed pregnancies before pregnancy recognition. Not taking a detailed alcohol history, including patterns of consumption, will result in under-detection of alcohol-exposed pregnancies. The Retrospective Diary offers practitioners a detailed way of enquiring about alcohol history for this population. This article is protected by copyright. All rights reserved.
Symon, A, Pringle, J, Cheyne, H, Downe, S, Hundley, V, Lee, E, Lynn, F, McFadden, A, McNeill, J, Renfrew, MJ, Ross-Davie, M, van Teijlingen, E, Whitford, H & Alderdice, F 2016, 'Midwifery-led antenatal care models: mapping a systematic review to an evidence-based quality framework to identify key components and characteristics of care', BMC PREGNANCY AND CHILDBIRTH, vol. 16.View/Download from: Publisher's site
Symon, A, Rankin, J, Sinclair, H, Butcher, G, Smith, L, Gordon, R & Cochrane, L 2016, 'Peri-Conceptual and Mid-Pregnancy Alcohol Consumption: A Comparison between Areas of High and Low Deprivation in Scotland', BIRTH-ISSUES IN PERINATAL CARE, vol. 43, no. 4, pp. 320-327.View/Download from: UTS OPUS or Publisher's site
Andrews, EJ, Symon, A & Anderson, AS 2015, ''I didn't know why you had to wait': an evaluation of NHS infant-feeding workshops amongst women living in areas of high deprivation.', Journal of Human Nutrition and Dietetics, vol. 28, no. 6, pp. 558-567.View/Download from: UTS OPUS or Publisher's site
Inappropriate maternal and infant-feeding practices are known to have a major impact on morbidity in infancy, childhood and later life. Ring-fenced funding over 3 years from the Scottish Government to the National Health Service (NHS) in Scotland has allowed the development of a range of nutrition interventions for women of childbearing age and infants living in areas of deprivation to help address these issues. The present study aimed to determine mothers' knowledge of appropriate infant-feeding practices, opinions about feeding advice and any changes in practice following attendance at workshops.Fifteen semi-structured interviews with women who participated in NHS infant-feeding workshops. Verbatim transcripts were analysed using framework analysis.Participants appreciated the opportunity to enhance their knowledge and there was evidence of a reasonable understanding and awareness of appropriate infant-feeding behaviours following workshop attendance. However, the findings highlight the challenge of multiple sources of advice and identify persistent uncertainties about feeding practice. Reported feeding behaviour following workshops was encouraging (e.g. delayed weaning, increased use of -prepared fruits and vegetables), although there was also evidence of resistance to change. The legacy of the workshop in terms of reported confidence in infant feeding was also apparent.The workshops appears to aid current knowledge and practice about infant feeding but further work is needed to examine the long term impact of these interventions on maternal and infant dietary behaviours.
Symon, A, Downe, S, Finlayson, KW, Knapp, R & Diggle, P 2015, 'The feasibility and acceptability of using the Mother-Generated Index (MGI) as a Patient Reported Outcome Measure in a randomised controlled trial of maternity care', BMC MEDICAL RESEARCH METHODOLOGY, vol. 15.View/Download from: Publisher's site
Symon, A, Williams, B, Adelasoye, QA & Cheyne, H 2015, 'Nocebo and the potential harm of "high risk' labelling: a scoping review', JOURNAL OF ADVANCED NURSING, vol. 71, no. 7, pp. 1518-1529.View/Download from: Publisher's site
Symon, A, Winter, C & Cochrane, L 2015, 'Exploration of preterm birth rates associated with different models of antenatal midwifery care in Scotland: Unmatched retrospective cohort analysis', MIDWIFERY, vol. 31, no. 6, pp. 590-596.View/Download from: Publisher's site
Lagan, BM, Symon, A, Dalzell, J & Whitford, H 2014, ''The midwives aren't allowed to tell you': perceived infant feeding policy restrictions in a formula feeding culture - the Feeding Your Baby Study.', Midwifery, vol. 30, no. 3, pp. e49-e55.View/Download from: UTS OPUS or Publisher's site
to explore the expectations and experiences of postnatal mothers in relation to infant feeding, and to identify how care could be improved.
this study used a qualitative, exploratory, descriptive design. Data were collected through one to one in-depth semi-structured interviews and focus groups.
Tayside area of Eastern Scotland.
seven focus group interviews (n=38 participants) and 40 semi-structured one-to-one interviews with mothers with a range of infant feeding experiences i.e. exclusively breast fed; started breast feeding but changed to formula milk before 16 weeks; exclusively formula fed; or who concurrently breast and formula fed their infant.
a principal theme of ‘Mixed and missing messages’ emerged, incorporating ‘Conflicting advice’, ‘Information gaps’ and ‘Pressure to breast feed’ with a secondary theme of ‘Emotional costs’. Several problems were identified with how women were given information, how infant feeding discussions were held, and the type of support available after the infant is born.
there was a strong perception that some midwives are not ‘allowed’ to discuss or provide information on formula feeding, and the women reported feeling pressurised to breast feed. Current interpretation of guidance from the UNICEF UK Baby Friendly Initiative may be restricting antenatal discussions about infant feeding. The combination of this partial preparation antenatally and postnatal support that was often inconsistent seems to incur a counter-productive emotional cost.
Implications for practice
at strategic, policy and practice levels the infant feeding message needs to change to encourage a more woman-centred focus including discussions about the realities of all types of infant feeding. It is important that health providers continue to promote and support breast feeding; and that effective services are provided to women who wish to breast feed to help them to do so. However prov...
Donnan, PT, Dalzell, J, Symon, A, Rauchhaus, P, Monteith-Hodge, E, Kellett, G, Wyatt, JC & Whitford, HM 2013, 'Prediction of initiation and cessation of breastfeeding from late pregnancy to 16 weeks: the Feeding Your Baby (FYB) cohort study', BMJ OPEN, vol. 3, no. 8.View/Download from: UTS OPUS or Publisher's site
Khabiri, R, Rashidian, A, Montazeri, A, Symon, A, Foroushani, AR, Arab, M & Rashidi, BH 2013, 'Validation of the Mother-Generated Index in Iran: A Specific Postnatal Quality-of-Life Instrument.', International journal of preventive medicine, vol. 4, no. 12, pp. 1371-1379.View/Download from: UTS OPUS
BACKGROUND: The mother-generated index (MGI) is one of only a few existing specific questionnaires for assessing the postnatal quality of life (QoL). MGI is a single-form questionnaire that asks postnatal mothers to specify up to eight areas of their lives which have been affected by giving birth to a baby. Using this tool, it is possible to score and rank the QoL of mothers. This study aimed to validate the questionnaire for use in Iran. METHODS: Forward translation was used to translate the questionnaire from English to Farsi (Persian). The questionnaire was then administered to a sample of postnatal women attending two teaching hospitals in Tehran, Iran. Face validity and criterion validity were performed to establish the validity for the Iranian version of the MGI. Face validity was assessed by asking women to indicate whether they understood the wording of the questions, how easy the questionnaire was, and so on. Criterion validity was examined using the Short Form 36-item (SF-36) Health Survey. It was hypothesized that the MGI would significantly correlate with the SF-36. RESULTS: In all, 124 women were approached. Of these, 119 women were eligible and 96 women agreed to take part in the study. Face validity was good and all of the women found the MGI straightforward to complete; as criterion validity, the MGI scores and the subscales of the SF-36 were moderately correlated (for all subscales: Pearson r > 0.4; P < 0.001). The mean MGI primary score was 5.38 (SD = 3.05). Women who had comorbidity had significantly lower MGI scores than women without comorbidity (P = 0.04). Correlation between aggregate of comments and primary score was high (r = 0.68, P < 0.01). CONCLUSIONS: In general, the Iranian version of the MGI performed well and our data suggest that it is a valid measure to assess health-related QoL among postnatal women.
Symon, A, Nagpal, J, Maniecka-Bryla, I, Nowakowska-Glab, A, Rashidian, A, Khabiri, R, Mendes, I, Bezerra Pinheiro, AK, de Oliveira, MF & Wu, L 2013, 'Cross-cultural adaptation and translation of a quality of life tool for new mothers: a methodological and experiential account from six countries', JOURNAL OF ADVANCED NURSING, vol. 69, no. 4, pp. 970-980.View/Download from: UTS OPUS or Publisher's site
Fenwick, JH, Hammond, AD, Raymond, JJ, Smith, RA, Gray, J, Foureur, M, Homer, CS & Symon, A 2012, 'Surviving, Not Thriving: A Qualitative Study Of Newly Qualified Midwives' Experience Of Their Transition To Practice', Journal Of Clinical Nursing, vol. 21, no. 13-14, pp. 2054-2063.View/Download from: UTS OPUS or Publisher's site
Aim and objectives. The study explored the experiences of newly qualified midwives and described the factors that facilitated or constrained their development during the transition from student to registered midwife.
Byrom, S & Symon, A 2011, 'Developing the midwife's role in public health.', The practising midwife, vol. 14, no. 1, pp. 16-17.
There is widespread acceptance that health can be shaped by factors occurring as far back as infancy, and even before birth. In September 2010 the document Midwifery 2020: Delivering Expectations was launched in Edinburgh. The aim of the report was to establish the future direction for midwifery in the UK, and included specific reference to the midwife's public health role. The report notes that experiences from in utero development until eight years of age lay critical foundations for the entire life course. The report reiterates previous debate on the important contribution maternity services have in addressing health inequalities, and emphasises the importance of midwives striving to address the needs of the most vulnerable communities they serve.
Symon, A & Dobb, B 2011, 'Maternal quality of life assessment: the feasibility of antenatal-postnatal follow-up using the Mother-Generated Index', JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY, vol. 29, no. 2, pp. 183-194.View/Download from: Publisher's site
Symon, A, Winter, C, Donnan, PT & Kirkham, M 2010, 'Examining Autonomy's Boundaries: A Follow-up Review of Perinatal Mortality Cases in UK Independent Midwifery', BIRTH-ISSUES IN PERINATAL CARE, vol. 37, no. 4, pp. 280-287.View/Download from: Publisher's site
Symon, A, Winter, C, Inkster, M & Donnan, PT 2009, 'Outcomes for births booked under an independent midwife and births in NHS maternity units: matched comparison study', BRITISH MEDICAL JOURNAL, vol. 338.View/Download from: Publisher's site
Symon, A 2007, 'Commentary on Hung C-H (2006) Revalidation of the postpartum stress scale. Journal of Clinical Nursing 15, 718-725.', Journal of clinical nursing, vol. 16, no. 9, pp. 1771-1772.View/Download from: Publisher's site
Cheyne, H, Hundley, V & Symon, A 2003, 'Policy, practice and research: does it make a difference?', RCM midwives : the official journal of the Royal College of Midwives, vol. 6, no. 12, pp. 526-528.
BACKGROUND: Contemporary broad descriptions of health and well-being are reflected in an increasing appreciation of quality of life issues; in turn this has led to a growing number of tools to measure this. METHODS: This paper reviews articles cited in MEDLINE, CINAHL and BIDS which have addressed the concept of quality of life in pregnancy and the period following childbirth. RESULTS: It describes five groups of articles: those explicitly assessing quality of life in this area; those using broader health assessments as an indicator of quality of life; those articles equating quality of life with certain pregnancy outcomes in identified groups of patients; those studies which identify the possibility of pregnancy as an outcome measure and infer from this that quality of life has been improved; and those articles which are themselves reviews or commentaries of pregnancy and childbirth and which identify quality of life as a feature. CONCLUSIONS: The term 'quality of life' is used inconsistently in the literature. There are few quality of life tools specifically designed for the maternity care setting. Improved or adversely affected quality of life is frequently inferred from certain clinical conditions.
Symon, A, Glazener, CMA, MacDonald, A & Ruta, D 2003, 'Pilot study: quality of life assessment of postnatal fatigue and other physical morbidity', JOURNAL OF PSYCHOSOMATIC OBSTETRICS AND GYNECOLOGY, vol. 24, no. 4, pp. 215-219.View/Download from: Publisher's site
Symon, A, MacKay, A & Ruta, D 2003, 'Postnatal quality of life: a pilot study using the Mother-Generated Index', JOURNAL OF ADVANCED NURSING, vol. 42, no. 1, pp. 21-29.View/Download from: Publisher's site
Symon, A, McGreavey, J & Picken, C 2003, 'Postnatal quality of life assessment: validation of the Mother-Generated Index', BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY, vol. 110, no. 9, pp. 865-868.View/Download from: Publisher's site
Wrieden, WL & Symon, A 2003, 'The development and pilot evaluation of a nutrition education intervention programme for pregnant teenage women (food for life)', JOURNAL OF HUMAN NUTRITION AND DIETETICS, vol. 16, no. 2, pp. 67-71.View/Download from: Publisher's site
Symon, A, MacDonald, A & Ruta, D 2002, 'Postnatal quality of life assessment: Introducing the Mother-Generated Index', BIRTH-ISSUES IN PERINATAL CARE, vol. 29, no. 1, pp. 40-46.View/Download from: Publisher's site
Symon, A 1999, 'Interprofessional and peer criticism: a side-effect of litigation?', Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology, vol. 19, no. 3, pp. 248-252.View/Download from: Publisher's site
Claims about a rising litigation rate, particularly in obstetrics, have allegedly fuelled fears of worsening relationships between obstetricians and midwives. Interviews with a number of practitioners, and others concerned with medical litigation, provided differing views about these assertions. While the fear of litigation is one element, it is probable that other often personal-factors may play a part. The overall tone of the interviews, however, suggested a significant degree of tension between obstetric and midwifery practitioners. The changing role of the midwife in contemporary maternity care also brings fresh challenges in developing healthy inter-professional relationships. At a time when litigation is believed to be ever-increasing, the existence of poor work relationships in this multi-disciplinary field may be critical.
Symon, A 1999, 'Perinatal litigation in Scotland 1980-1995: its incidence, rate and nature.', Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology, vol. 19, no. 3, pp. 239-247.View/Download from: Publisher's site
Many claims about an increase in the incidence of perinatal litigation have been made, despite a lack of comprehensive data which might confirm this. A large scale study into litigation throughout Scotland from 1980 to 1995 revealed an initial sharp rise in the number of claims, but a fall in the overall number of claims made in 1994 and 1995; a similar picture was noted in a limited cross-border examination of English files. Not every area has experienced a reduction in incidence, and the rate of litigation (measured in deliveries per legal claim) varied hugely over time and between areas. A wide variety of head of claim was noted. Twenty-one percent of Scottish claims concerned cerebral palsy; of closed claims only 15% were successful, but a large proportion are still on-going. While the 'litigation crisis' is difficult to verify from these data, costs appear to be rising.
Cunningham, S, Deere, S, Symon, A, Elton, RA & McIntosh, N 1998, 'A randomized, controlled trial of computerized physiologic trend monitoring in an intensive care unit', CRITICAL CARE MEDICINE, vol. 26, no. 12, pp. 2053-2060.View/Download from: Publisher's site
Symon, A & Cunningham, S 1995, 'Handling premature neonates: a study using time-lapse video.', Nursing times, vol. 91, no. 17, pp. 35-37.
Handling procedures in the neonatal intensive care unit (NICUs) constitute a potential hazard for very pre-term infants. This study examines whether the presence of continuous physiological trend data on a cot-side monitor affects the overall length of time an infant is handled. This was done by pairing infants by gestational age and assessing the frequency and length of handling procedures, using a video recorder in time-lapse mode. No consistent correlation was found between handling duration and either continuous monitoring, gestational age, birth weight or ventilatory status. We also compare the actual numbers of handling episodes and the length of time spent being handled with the perceptions of handling among NICU staff. The study was constrained by the requirements of a larger study examining the effects of the cot-side monitors, and so numbers recruited were small and our conclusions tentative at best; however, the discrepancy between what staff thought handling rates were and what we observed indicates that there may be room for considerable improvements in the planning of care giving to very vulnerable infants.
Symon, A & Cunningham, S 1994, 'Nasogastric feeding methods in neonates.', Nursing times, vol. 90, no. 35, pp. 56-60.