Tool about physical therapy practice in neonatal sensory motor stimulation: a Delphi studyAbstract
Introduction Neonatal sensory motor stimulation (SMS) interventions are designed to enhance the neuropsycho-motor and sensory development of newborns. Despite their potential benefits, the lack of standardized in SMS procedures among professionals highlights the need for a unified approach to improve outcomes.
Objective To develop an instrument for collecting information on neonatal SMS procedures used by Brazilian physiother-apists, including parameters for monitoring stress signs or self-regulation in newborns.
Methods Conducted research using the Delphi method with an online panel of experts in neonatal intensive therapy. The content cov-ered 10 SMS techniques, cardiorespiratory parameters, and behavioral states. Consensus was evaluated through content validity calculations using a four-point Likert scale. Descriptive questions regarding the instrument’s adequacy were analyzed using the Bardin's content analysis method.
Results Thirteen specialists participate via email. The development of the instrument required two rounds rounds of review. Agreement rates were 53-69% in the first round and of 83-100% in the second. The final version comprised 212 questions, covering all categories of SMS procedures (tactile, vestibular, olfac-tory/gustative, and visual).
Conclusion A comprehensive list of 221 questions across four SMS categories was developed. This instrument's clinical relevance lies in its ability to standardize and monitor SMS application, thereby promoting consistent and effective neonatal care.
Delphi method; Newborn; Neonatal Intensive Care Unit; Physiotherapy; Sensory motor stimulation
Resumo
Introdução A estimulação sensoriomotora neonatal (ESM) compõe intervenções que visam melhorar o desenvolvimento do recém-nascido. No entanto, a falta de padronização nos procedimentos de ESM destaca a necessidade de identificar as estratégias utilizadas.
Objetivo Desenvolver um instrumento de coleta de informações sobre os procedimentos de ESM realizados por fisiote-rapeutas brasileiros, incluindo parâmetros para monitorar sinais de estresse ou autorregulação no recém-nascido.
Métodos Trata-se de uma pesquisa online conduzida pelo método Delphi, com a participação de um painel de especialistas para avaliação do consenso. Para a construção do conteúdo foram consideradas dez técnicas de ESM, parâmetros cardiorrespiratórios, estado compor-tamental, entre outras variáveis. O consenso foi avaliado através do cálculo da validade de conteúdo por meio da taxa de concordância. Para as questões descritivas referentes à adequação do instrumento, as tendências de respostas e as respostas dissonantes foram sistematizadas pelo método de Bardin.
Resultados Treze especialistas participaram do estudo. A construção do instru-mento demandou duas rodadas entre as categorias dos procedimentos de ESM, com taxas de concordância de 53-69% na primeira rodada e de 83-100% na segunda. A versão final foi construída com 212 questões e con-templou todas as categorias de procedimentos de ESM (tátil, vestibular, olfatória/gustativa e visual).
Conclusão Uma lista de 221 questões distribuídas em quatro cate-gorias de procedimentos de ESM foi considerada relevante para atender um instrumento de coleta de infor-mações sobre os procedimentos de ESM. A relevância clínica deste instrumento reside em sua capacidade de padronizar e monitorar a aplicação de ESM, permitindo uma abordagem mais consistente e eficaz para promo-ver melhor cuidado neonatal.
Método Delphi; Recém-nascido; Unidades de Terapia Intensiva Neonatal; Fisioterapia; Estimu-lação sensoriomotora
Introduction
The Ministry of Health's Ordinance 930, issued in 2012, established guidelines and objectives for organiz-ing comprehensive and humanized newborn (NB) care. This ordinance underscores the crucial role of physio-therapists as integral members of Neonatal Intensive Care Unit (NICU) teams.1 In recent years, physiotherapists have increasingly concentrated on sensory motor organi-zation strategies,2 environmental enrichment,3 and stress reduction in daily care4 through various sensory motor stimulation (SMS) protocols.5
SMS procedures include a range of interventions developed to organize the neuropsychomotor and sensory systems of NBs, who may be at risk for develop-mental challenges in sensory, motor, and neurological domains.5-7 While the routine for these procedures evolves over time and varies culturally across Brazilian regions, their implementation demands both technical expertise and scientific knowledge. Moreover, unified strategies are essential to achieve potential short-term and long-term developmental outcomes.8 In 2021, the first Brazilian physioterapy recommendations for SMS of NBs and infants in NICUs were established provid-ing physiotherapy professionals with specific, evidence-based guidelines. 5
Currently, there is a challenge in standardizing various SMS procedures and their outcomes in NBs. Developing strategies to systematically track this information could significantly inform neonatal care practices by providing a solid foundation for SMS implementation. Creating an instrument to identify the SMS techniques applied by physiotherapists in NICUs, along with the parameters used to monitor stress indicators or self-regulation in NBs will facilitate team standardization, ultimately enhancing the quality of NB care.
In this context, the development of an instrument based on consensus among a group of experts, con-sidering diverse perspectives on a subject within the same field, can be facilitated by the Delphi method.9-11 This approach has proven to be a valuable asset in the research design phase due to its specificity, increasing the effectiveness of the instruments.9,10 Typically con-ducted online, the Delphi method offers several advan-tages, including structured information flow, systematic feedback, cost-effectiveness, interactive engagement, and participant anonymity.12
Considering the scarcity of data on SMS procedures conducted by physiotherapists in Brazilian NICUs and the potential future impact of a guiding instrument's results on professional practice and neonatal physiotherapy care quality, this study sought to create an instrument for gathering information about neonatal SMS procedures performed by Brazilian physiotherapists. This instrument also includes parameters for monitoring stress indicators and self-regulation in NBs.
Methods
This research received approval by the Human Research Ethics Committee of Universidade do Estado de Santa Catarina (CAAEE 15263219.0.0000.0118), was conducted online through multiple rounds using the Delphi method.
During the instrument development phase, neonatal intensive care physiotherapy experts were consulted (Figure 1).
Development of the instrument's content
The initial version of the instrument, including 228 questions with 221 of which were multiple-choice, was presented to the expert panel. The content for this first version was developed using the standard operating procedure (SOP) for neonatal SMS from Sofia Feldman Hospital (Hospital Sofia Feldman HSF) in Belo Horizonte, Minas Gerais. This SOP was founded on scientific litera-ture about SMS and the routine care practices in HSF's maternity and neonatal units, considering the high vol-ume of NBs receiving care. HSF is recognized as one of the country's leading maternity hospitals, boasts the Baby-Friendly Hospital designation, and offers 41 inten-sive care beds alongside 45 intermediate care beds, including 30 conventional and 15 kangaroo care units.
Instrument consensus
To reach a consensus, two rounds of consultations were conducted with 13 expert physiotherapists spe-cializing in NICU care from different regions of Brazil.11 The experts were invited to participate in the study via email, and those who accepted received the instrument through Google Forms®.
Physiotherapists were instructed to assess the clarity and significance of the instrument's content in relation to clinical practice,13 over a 15-day period. During each subsequent round, experts could contribute additional information and comment on any unaddressed con-tent at the end of the instrument. The coordinator analyzed response patterns and divergent answers in all rounds, organizing them for further evaluation. The rounds concluded when a consensus of at least 70% was achieved for each category of SMS procedures, including tactile, vestibular, olfactory/gustatory, and vi-sual stimulations.8,14
Data processing
Consensus was determined by calculating content validity using the agreement rate, applied through the formula: agreement % = (number of agreeing members/total number of members) x 100. To evaluate the level of expert consensus, a four-point Likert scale was used, with items 1 (not at all clear) and 2 (somewhat unclear) considered as disagreement, while items 3 (clear) and 4 (very clear) were deemed agreement. For the descriptive items about the instrument's adequacy, responses were categorized as either adequate (agree) or inadequate (disagree).15 Items scoring 1 or 2 were either revised or eliminated from the instrument. Response patterns and discrepancies were analyzed using Bardin's method.16 For this analysis, data was organized into tables based on content similarity (Table 1).16,17 Revised items were inserted into Microsoft Office Excel (Excel®, Natick-MA) and presented as absolute frequencies.
Results
Instrument development
All 13 physiotherapists initially invited to form the consensus panel agreed to participate. However, one withdrew during the second round, leaving 12 participants who completed both rounds and approved the final version of the instrument. This approved version includes 212 questions, categorized into four procedural categories: 105 tactile, 30 vestibular, 30 olfactory/gus-tatory, and 28 visual, along with 19 items on supplementary data (Appendix 1). The expert panel, composed entirely of women, included nine holding master's degrees. Ten of the experts practiced neonatal clinical work across four of Brazil's five geographical regions.
Instrument consensus
Table 1 includes the adjustments made to items reviewed through descriptive analysis using Bardin's method. During the information summary, three adjustments were made to address nomenclature discrepan-cies. The initial agreement rate was 69% in the first round, which improved to 83-100% across items in the second round (Table 2).
Discussion
The aim of this study was to develop an assessment instrument using the Delphi method to evaluate the practices of Brazilian physiotherapists in NICU SMS. The study involved two rounds of the Delphi method and three refinements to finalize the instrument, which was subsequently implemented. While some physiotherapy research has used this method,18-20 to the best of our knowledge, this study is the first study in Brazil to detail the procedures applied by physiotherapists in NICUs.
The Delphi method, originally developed in 1950,21 was introduced to the scientific community in the 1980s and gained widespread, structured dissemination from the 2000s onward.21,22 This method has emerged as a valuable tool in research development, owing to its specificity and ability to enhance the effectiveness of developed instruments.9
Research in physiotherapy using the Delphi method has produced instruments with diverse aims, including evaluating students' cardiorespiratory physiotherapy skills, quantifying client behavior in neonatal care prac-tices, and assessing sleep promotion techniques in adult intensive care units.18-20 Each study used an expert panel to gather opinions and established consensus through rigorous agreement analysis, supporting the methodology used in this study.
An essential aspect was the methodology outlined for reaching expert consensus. Given the lack of high-quality evidence to guide neonatal practices, efforts were made to develop clinical practice guidelines. The various rounds revealed that stakeholders have di-verse priorities in neonatal care. Longo et al.´s study23 appropriately incorporates parents of hospitalized NB into the expert panel. This inclusive approach is particularly significant when addressing infant and neona-tal populations, as parents play a vital role in present-ing desired and achieved outcomes. It exemplifies the biopsychosocial model highlighted by the Internatio-nal Classification of Functioning, Disability and Health, changing the focus of patient care away from a disease-centric approach and integrating environmental factors and, crucially, parental involvement throughout the care process, including this important aspect.23
Webbe et al.24 gathered an assessment panel in-volving parents and healthcare professionals to develop a neonatal clinical practice guidance instrument. Despite differing interests among panel experts, the method enabled reaching consensus on key topics. While all mentioned studies examined outcomes related to physiotherapy care,18-20,24 none specifically addressed neonatal SMS procedures or the various interventions aimed at optimizing neuropsychomotor development, guaran-teeing NB stability and physiological regulation, and mitigating the effects of the NICU environment.6,25,26
An important Brazilian study compiled SMS recom-mendations for NBs and infants in ICUs. The research used a comprehensive literature review, incorporating 89 SMS articles and expert opinions from physiotherapists specialized in the field.5 The authors classified SMS into two categories: unimodal stimulation (tactile, vestibu-lar, auditory, olfactory, gustatory, and visual) and multi-modal stimulation (tactile-kinesthetic, therapeutic mas-sage, skin-to-skin contact, multisensory stimulation, and exercises/mobilization). This classification highlights the diversity of care practices and their efficacy in various aspects, such as weight gain, improved sucking reflexes and vital signs, as well as pain and stress management in NBs.5
In contrast to the initial Brazilian recommendation, this study opted to differentiate the techniques associ-ated with neonatal SMS to identify the resources used by physiotherapists, irrespective of scientific evidence. The items chosen in the first round of the Delphi method for the instrument were derived from the SOP of a maternity hospital in southeastern Brazil, which par-ticipates in the Vermont Oxford Network database and serves as a reference for the Stork Network. Supporting this diversity of procedures intrinsic to care practices, the categories related to visual and olfactory/gustatory systems underwent the most significant changes in this study, ultimately achieving a 91% agreement rate after adjustments.
Using the instrument developed in this study, the aim is to monitor care practices related to neonatal SMS in NBs and infants.5 Additionally, future research may benefit from administering this instrument to fur-ther explore the protocols for each category. While acknowledging this future progress, we recognize the instrument's length as a limitation. A document includ-ing 212 questions may require more time to complete; however, this comprehensive approach is essential to address all procedures in NICUs and capture several in-sights from the physiotherapist's perspective regarding applicability and effects on NBs.
Conclusion
A set of 221 questions, categorized into four pro-cedure types, was deemed essential for developing an instrument to collect data on neonatal SMS prac-tices among Brazilian physiotherapists. This clinical sig-nificance lies in its ability to standardize and monitor the implementation of neonatal SMS, facilitating a more uniform and efficient approach to improving neonatal care.
Acknowledgements
This work was carried out with the support and financial assistance of the Coordination for the Improve-ment of Higher Education Personnel (CAPES), a Brazilian Government entity focused on training human resources, and the National Council for Scientific and Technological Development (CNPq).
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Edited by
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Associate editor:
Ana Paula Cunha Loureiro
Note: *Calculation of agreement rate.