The role of managers in promoting good hand hygiene in a Finnish tertiary care hospital.

BACKGROUND: Hospital managers play an essential role in implementing strategies to promote good hand hygiene (HH) among health care workers. We investigated the managers' views on their roles, challenges and developmental ideas in promoting good HH practice. METHODS: A descriptive cross-sectional study with an online survey of both medical and nursing managers was conducted within a single tertiary care hospital in Finland. Three open-ended questions were analyzed using inductive content analysis. RESULTS: A total of 78 managers out of 168 responded to the survey (response rate 46%). Managers helped promote HH practices by enabling the proper environment for adherence to good HH, visible commitment, and using various means to instruct staff about HH. Challenges included the acute hospital setting and practical problems related to the managers' numerous responsibilities. Developmental ideas included information communication technology applications for monitoring HH as an indicator of the quality of care, versatile responses to HH audits, and clarifying the roles of different management levels. CONCLUSIONS: Managers are committed to and use various methods to promote HH. Managers would benefit from information communication technology applications to provide easy and targeted information regarding compliance with HH.

Increasing nursing students' knowledge of evidence-based hand-hygiene: A quasi-experimental study.

Aim of study was to evaluate the effects of a multi-component intervention on nursing students' knowledge of evidence-based hand-hygiene. A quasi-experimental design was used. Nursing students (N = 146) from two universities of applied sciences (experimental group n = 107, control group n = 39) completed an instrument based on international clinical guidelines related to hand hygiene that consisted of 17 Likert-scale items. Data were collected at three time points (baseline, after university-based training and after clinical training) between autumn 2014 and spring 2016. Group differences were examined using chi-squared or Fisher Exact tests, the Mann-Whitney and U test. Within-group differences were assessed with the McNemar test for paired nominal data. At the first and second time points the experimental group had better hand hygiene knowledge than the controls. There were no group differences in responses to items concerning the appropriate length of hand disinfection. The experimental group showed improvements in the practice of washing hands with soap and water, but not in the other statements concerning hand disinfection. Theoretical recap and training at school seemed to influence students' hand hygiene knowledge, but reinforcement during clinical training may be required to ensure that learning practical evidence-based skills, such as hand-hygiene, may be established.

Nurses' perceptions of pain assessment and management practices in neonates: a cross-sectional survey.

AIMS: This study aimed to describe pain assessment and management practices for neonates based on nurses' perceptions in neonatal intensive care units (NICUs). DESIGN: A descriptive cross-sectional survey was conducted in Finland. METHODS: Of all nurses (N = 422) working in the NICUs in the country's five university hospitals, 294 responded to a questionnaire. The data were analysed by statistical methods. RESULTS: Nurses agreed that pain assessment is important, but over half of them reported being able to assess pain in a reliable way without using pain assessment scales. Physiological parameters and changes in neonate's behaviour were reported as routinely observed, but many specific facial expressions indicative of pain were less often observed. Only a few pain assessment scales were known, and they were not routinely used in clinical practice. Most nurses reported using physical methods and giving oral sucrose along with non-nutritive sucking. Counselling parents to continue breastfeeding or guiding them to use skin-to-skin care or music was rarely reported as used to alleviate infants' pain. CONCLUSIONS: Educational interventions for nurses are needed to improve pain assessment and management practices in the NICUs. In addition, there is a need for national guidelines in order to ensure the equal treatment to all neonates.

Parents' Use of Nonpharmacologic Methods to Manage Procedural Pain in Infants.

OBJECTIVE: To describe parents' use of nonpharmacologic methods to manage infant procedural pain in the NICU and determine the demographic factors related to such use. DESIGN: A cross-sectional and descriptive study design. SETTING: Level III and Level II NICUs (seven units) of four University Hospitals in Finland. PARTICIPANTS: Parents (N = 178) whose infants were treated in Finnish NICUs. METHODS: Parents were asked to respond to a structured questionnaire during their infants' hospitalizations. We analyzed the data using the nonparametric Kruskal-Wallis one-way analysis of variance and Mann-Whitney U test. RESULTS: Most parents reported that they used physical methods, such as touching, holding, and positioning, nearly always/always (86%, 76%, and 55%, respectively). However, less commonly used strategies included recorded music (2%), breastfeeding (2%), and non-nutritive sucking with oral sucrose (6%). Many characteristics of the infants, such as their gestational ages and their conditions, were significantly related to the implementation of nonpharmacologic methods. CONCLUSION: There is a clear need to extend parents' use of nonpharmacologic methods to manage their infants' procedural pain in the NICU. Because many methods were not considered as pain-relieving strategies, it is important to increase knowledge about the effectiveness of these interventions among parents and nurses.

The development of ethical guidelines for nurses' collegiality using the Delphi method.

BACKGROUND: Nurses' collegiality is topical because patient care is complicated, requiring shared knowledge and working methods. Nurses' collaboration has been supported by a number of different working models, but there has been less focus on ethics. AIM: This study aimed to develop nurses' collegiality guidelines using the Delphi method. METHOD: Two online panels of Finnish experts, with 35 and 40 members, used the four-step Delphi method in December 2013 and January 2014. They reformulated the items of nurses' collegiality identified by the literature and rated based on validity and importance. Content analysis and descriptive statistical methods were used to analyze the data, and the nurses' collegiality guidelines were formulated. Ethical considerations: Organizational approval was received, and an informed consent was obtained from all participants. Information about the voluntary nature of participation was provided. RESULTS: During the first Delphi panel round, a number of items were reformulated and added, resulting in 32 reformulated items. As a result of the second round, 8 of the 32 items scored an agreement rate of more than 75%, with the most rated item being collegiality means that professionals respect each other. The item with second highest rating was collegiality has a common objective: what is best for patients, followed by the third highest which was professional ethics is the basis of collegiality. CONCLUSION: Nurses' collegiality and its content are well recognized in clinical practice but seldom studied. Collegiality can be supported by guidelines, and nurses working in clinical practice, together with teachers and managers, have shared responsibilities to support and develop it. More research in different nursing environments is needed to improve understanding of the content and practice of nursing collegiality.

Nurses' and Parents' Perceptions of Parental Guidance on Using Nonpharmacological Pain-Relieving Methods Among Neonates in the NICU.

Despite growing knowledge of parents' important role in their infants' pain management, the extent to which nurses in neonatal intensive care units (NICUs) provide guidance to parents on nonpharmacological methods is unclear. This study aimed to describe and compare the perceptions of parental guidance in using nonpharmacological pain-relieving methods among neonates in NICUs from the viewpoints of nurses and parents, and to examine the participants' demographics related to the guidance. A cross-sectional, descriptive, correlational study using questionnaire surveys was conducted. Eight NICUs of 5 university hospitals in Finland. A total of 427 participants, including 294 nurses and 178 parents. The participants indicated that the methods of touching and holding were the most commonly introduced strategies in infants' pain alleviation, as they were given as an alternative "nearly always/always" (nurses 91%, 87% and parents 61%, 58%, respectively). In contrast, music and breast-feeding were the less commonly introduced nonpharmacological methods (nurses 11%, 6% and parents 1%, 6%, respectively). A significant difference (p < .001) was found between the parents' and nurses' perceptions of parental guidance; nurses reported providing more guidance about all nonpharmacological methods compared with parents. In addition, many demographic factors of the nurses, the parents, and their infants were related to the parental guidance. Our findings indicate that parental guidance should not be based on nurses' evaluations of their activities without taking into account parents' perspectives. When counseling parents to use nonpharmacological methods, neonatal nurses should actively interact with families and discuss parents' individual needs.

Factors Influencing Parental Participation in Neonatal Pain Alleviation.

PURPOSE: Neonates are likely to experience numerous painful procedures in neonatal intensive care units (NICUs). Parents have expressed a wish to be more involved in their infants' pain alleviation. The purpose of this study was to describe parents' perceptions concerning the factors that influence parental participation in pain alleviation in an NICU. DESIGN AND METHODS: The qualitative study was conducted in level II and III NICUs (7 units) of Finland's four university hospitals. Data were collected through open-ended questionnaires and analyzed using inductive content analysis. RESULTS: Factors that promoted parental participation consisted of five main categories: parental counseling by staff, parents' awareness of their own role, parents' motivation to participate in pain relief, family-friendly facilities and good communication. Factors hindering parental participation consisted of eight categories, including restrictive environment, lack of knowledge, everyday life requirements, underestimation of parents, the nature of the medical procedures, procedure- and pain-related emotions, deteriorated health status of the child and mother and (8) uncertainty of parenting. CONCLUSIONS: This study revealed a number of factors that are important to take into account when improving parental involvement in neonatal pain alleviation. Especially, parental participation can be promoted by providing sufficient counseling based on the parents' needs and creating facilities that support parents' participation. PRACTICE IMPLICATION: Parents should be engaged as partners in caregiving and decision making, and they should be given space to assume the role of parents during their child's hospitalization.

Neonatal Intensive Care Nurses' Perceptions of Parental Participation in Infant Pain Management: A Comparative Focus Group Study.

This comparative focus group study explored nurses' experiences and perceptions regarding parental participation in infant pain management in the neonatal intensive care unit (NICU). A total of 87 nurses from 7 NICUs in Finland, Sweden, and the United States participated in focus-group interviews (n = 25). Data were analyzed using deductive and inductive thematic analysis. Nurses' experiences and perceptions varied considerably, from nurses being in control, to nurses sharing some control with parents, to nurse-parent collaboration in infant pain management. When nurses controlled pain management, parents were absent or passive. In these cases, the nurses believed this led to better pain control for infants and protected parents from emotional distress caused by infant pain. When nurses shared control with parents, they provided information and opportunities for participation. They believed parent participation was beneficial, even if it caused nurses or parents anxiety. When nurses collaborated with parents, they negotiated the optimal pain management approach for an individual infant. The collaborative approach was most evident for the nurses in the Swedish NICUs and somewhat evident in the NICUs in Finland and the United States. Further research is needed to address some nurses' perceptions and concerns and to facilitate greater consistency in the application of evidence-based best practices.

Adherence to hand hygiene guidelines - significance of measuring fidelity.

AIMS AND OBJECTIVES: The aim was to evaluate the usability of fidelity measures in compliance evaluation of hand hygiene. BACKGROUND: Adherence to hand hygiene guidelines is important in terms of patient safety. Compliance measures seldom describe how exactly the guidelines are followed. DESIGN AND METHODS: A cross-sectional observation study in a university hospital setting was conducted. Direct observation by trained staff was performed using a standardised observation form supplemented by fidelity criteria. A total of 830 occasions were observed in 13 units. Descriptive statistics (frequency, mean, percentages and range) were used as well as compliance rate by using a standard web-based tool. In addition, the binomial standard normal deviate test was conducted for comparing different methods used in evaluation of hand hygiene and in comparison between professional groups. RESULTS: Measuring fidelity to guidelines was revealed to be useful in uncovering gaps in hand hygiene practices. The main gap related to too short duration of hand rubbing. Thus, although compliance with hand hygiene guidelines measured using a standard web-based tool was satisfactory, the degree of how exactly the guidelines were followed seemed to be critical. CONCLUSIONS: Combining the measurement of fidelity to guidelines with the compliance rate is beneficial in revealing inconsistency between optimal and actual hand hygiene behaviour. RELEVANCE TO CLINICAL PRACTICE: Evaluating fidelity measures is useful in terms of revealing the gaps between optimal and actual performance in hand hygiene. Fidelity measures are suitable in different healthcare contexts and easy to measure according to the relevant indicators of fidelity, such as the length of hand rubbing. Knowing the gap facilitates improvements in clinical practice.

Mothers' perceptions of their health choices, related duties and responsibilities: A qualitative interview study.

OBJECTIVE: to describe mothers' perceptions of their health choices, related duties and responsibilities. DESIGN: descriptive exploratory study with qualitative research method. SETTING: interviews conducted after the clients' regular health visits to one publicly provided maternity clinic in a southern city in Finland. PARTICIPANTS: 13 mothers aged between 21 and 40-years-old, who were pregnant or had given birth in the past four weeks. Six of participants were pregnant or had delivered for first time and it was the second to fourth pregnancy for the remainder. DATA COLLECTION AND DATA ANALYSIS: one-to-one semi-structured interviews using the inductive content analysis method. FINDINGS: women reported increased responsibility for their health choices for themselves and their baby during pregnancy. However, their duties and responsibilities were seldom discussed at maternity clinics. The duty to reconsider their health choices was described as a predictor of commitment to their pregnancy and motherhood, but they recognised that it required sufficient knowledge to realise this. In addition, the mothers said their health choices changed from private to one of public interest during this period. CONCLUSIONS: health choices are connected to maternal duties and responsibilities, but they can sometimes lack clarity during this new phase of life. In future, more research should be conducted to study maternal duties and responsibilities in different contexts. IMPLICATIONS FOR PRACTICE: findings highlight the skills of nurses and midwives at maternity clinics to discuss and support mothers' moral pondering during pregnancy. Although health choices in general are well recognised as a part of maternal counselling, these findings suggest a moral perspective should be incorporated into the advice that is provided.

Professional ethics in nursing: an integrative review.

AIM: To conduct an integrative review and synthesize current primary studies of professional ethics in nursing. BACKGROUND: Professional ethics is a familiar concept in nursing and provides an ethical code for nursing practice. However, little is known about how professional ethics has been defined and studied in nursing science. DESIGN AND DATA SOURCES: Systematic literature searches from 1948-February 2013, using the CINAHL, PubMed and Scopus electronic databases to look at previously published peer-reviewed studies. REVIEW METHOD: A modified version of Cooper's five-stage integrative review was used to review and synthesize current knowledge. RESULTS: Fourteen papers were included in this research. According to our synthesis, professional ethics is described as an intra-professional approach to care ethics and professionals commit to it voluntarily. Professional ethics consist of values, duties, rights and responsibilities, regulated by national legislation and international agreements and detailed in professional codes. Professional ethics is well established in nursing, but is constantly changing due to internal and external factors affecting the profession. CONCLUSION: Despite the obvious importance of professional ethics, it has not been studied much in nursing science. Greater knowledge of professional ethics is needed to understand and support nurses' moral decision-making and to respond to the challenges of current changes in health care and society.

Development and preliminary validation of the Neonatal Infant Acute Pain Assessment Scale (NIAPAS).

BACKGROUND: Several pain scales are available for neonates, but, unfortunately they are only rarely used in clinical practice. To help with the current situation of unrecognized and under-treated pain in neonatal intensive care units (NICUs), we developed an assessment tool in close collaboration with clinical staff. OBJECTIVES: To develop a multidimensional scale, NIAPAS (the Neonatal Infant Acute Pain Assessment Scale), that is sensitive to the needs of infants in neonatal intensive care units, and to test the validity, reliability, feasibility and clinical utility of the scale for this population. DESIGN: Instrument development and psychometric analysis. METHODS: Pain assessments (n=180) were made of 34 neonates born between 23 and 42 weeks gestational age who were undergoing 60 painful procedures (heel lance 77%, tracheal suctioning 23%) in the NICU. Using bedside video recordings, each neonate was observed through three phases of the procedure: 1 min before the procedure, during the procedure (lasting from 0.6 to 11.2 min, mean 2.6), and 1 min after the procedure. In addition, an expert panel (n=5) and nurses (n=26) participated in the validation of the scale. RESULTS: A pool of 8 pain indicators (5 behavioral and 3 physiological indicators), including the gestational age of neonates as a contextual factor, was identified based on the nurses' expertise in neonatal intensive care. Scores on the NIAPAS changed significantly across the phases (p<0.001), indicating a good construct validity of the scale. Correlations between the NIAPAS and NIPS (the Neonatal Infant Pain Score) were high (0.751-0.873). The study also demonstrated high coefficients for inter-rater (r=0.991-0.997) and intra-rater reliability (r=0.992-1.00), with an internal consistency of 0.723. The content validity was very good (Mean I-CVI 1.00), as evaluated by the expert group. The nurses agreed that the scale was easy to administer and that it helped decision-making in the pain management of infants. CONCLUSIONS: The NIAPAS was shown to be a valid and reliable scale for assessing acute pain in preterm and full-term infants in the NICU. It allows nurses to evaluate infants' acute pain especially during painful procedures and help to provide pain relief for the infants.

Nurses' perceptions of the use of restraint in pediatric somatic care.

BACKGROUND: The interest in the children's role in pediatric care is connected to children's health-related autonomy and informed consent in care. Despite the strong history of children's rights, nurses' role in the everyday nursing phenomenon, that is, restraint in somatic pediatric care, is still relatively seldom reported. AIM: The aim of this study is to describe nurses' perceptions of the use of restraint in somatic pediatric care. The ultimate aim is to deepen the understanding of the phenomenon of restraint, whose previous study has been fragmented. METHODS: Qualitative approach was selected because of the lack of previous information. Due to the sensitivity of the research question, individual interviewees were selected among voluntary nurses (n = 8). All participants were registered nurses with general work experience as nurses of 5-16 years on average and specifically 1.5-10 years in pediatric nursing. Inductive content analysis was used for aiming to produce a synthesis of the research phenomenon. ETHICAL CONSIDERATIONS: The research received organizational approval by the university hospital, and informed consent and confidentiality were ensured. RESULTS: Restraint in pediatric nursing was process-like, but occurred without advanced planning. The restraint-related process included five categories: (a) identification of the situations where restraint may occur, (b) finding preventive methods, (c) identification of different forms of restraint, (d) rationing the use of restraint, and (e) post-restraint acts. Restraint was seen as a part of pediatric nursing which occurred daily and involved several professionals. According to the nurses' illustrations, restraint means doing things even when a child is not agreeable. CONCLUSION: Restraint is part of somatic pediatric nursing, described as the last, but in some cases, the only resort for carrying out care or treatment. Restraint is not a goal in itself, but an instrumental tool and procedure in carrying out care. In the future, more information about nurses' role and the use of restraint in pediatric nursing is still needed.

Nurses' narratives on termination of primary nursing relationship with parents in neonatal intensive care.

BACKGROUND: Primary nursing working model in the neonatal intensive care unit enables a long-lasting caring relationship with the infants and their parents. Terminating this kind of relationship is seldom discussed. AIM: The aim of the study was to describe nurses' experiences of terminating the primary nursing relationship with the parents in neonatal intensive care. METHODS: Qualitative design using narrative method was used because there is a little knowledge relating to the topic. The data were collected with active interviews and analysed with narrative analysis. Seven nurses with experience of neonatal intensive care and primary nursing were recruited by convenience sampling. The approval was granted according to the hospital guidelines. RESULTS: The results gave rise to the three narratives that described the relationship between the primary nurse and the parents as the nursing relationship ends. All narratives shared a common plot, 'regulation of the closeness on nursing relationship', but it was manifested in different ways in each narrative. The plot in the narratives changed on a closeness-distance axis according to how the primary nurse regulated the nursing relationship and its termination. In the first narrative, the regulation of the relationship promoted distance, in the second connection and in the third closeness and connection. CONCLUSIONS: The long-lasting nature of the primary nursing working model may allow different caring relationships which will be revealed in terminating phase of care. This phenomenon is poorly recognised. It is important to study the caring relationship between the primary nurse and the parents of a hospitalised child, because the caring relationship is the core of nursing and needs to be considered in research and supported in practice.

It's time for updating primary nursing in pediatric oncology care: qualitative study highlighting the perceptions of nurses, physicians and parents.

PURPOSE: The aim of the study was to describe nurses', physicians' and parents' perceptions of primary nursing as a working model in a paediatric oncology care setting. METHOD: The qualitative descriptive approach was selected in order to obtain rich content by exploring of individual perceptions related to the experiences of primary nursing. Focus group interviews were used with staff and individual interviews with the parents. Data from different participants were analysed together by using inductive content analysis. RESULTS: Primary nursing was revealed as a confused and unstructured tradition which allowed variation in the role of the primary nurse and in the process. Within the role of a primary nurse, the orientation to primary nursing varied consisting of coordinating of care, task orientated and relation orientated primary nursing. The starting of the process was sudden and accidental by nature involving the aspects of commencement and allocation of the process. At the end of the process different emphasis existed in terms of the length of the process as highlighting early phase, comprehensive process and never getting to the end. Staff notions varied more than those of the parents. CONCLUSION: Perceptions related to primary nursing as a working model were revealed to be confusing by nature from the point of view of all involved. Thus, clarification is needed in the role of primary nurses and the process of primary nursing in order to gain expected family and organisational outcomes.

Nurses' perspectives on the suffering of preterm infants.

The concept of suffering is discussed among those who are cognitively aware and verbally capable to express their suffering. Due to immaturity, preterm infants' abilities to express suffering are limited. Relieving suffering is an ethical and juridical demand of good nursing care. The purpose of this study is to describe nurses' perceptions of the suffering of preterm infants. A descriptive qualitative approach was selected. Data were collected from essays written by nurses (n = 19) working in the neonatal intensive care unit. Inductive content analysis guided by the research question was performed. The nurses described individually determined suffering of the preterm infants according to four categories: suffering ruled by maturation, existence of suffering, individual threshold of suffering and interpreting the cues of suffering. Suffering of preterm infants is manifested by population-specific features, emphasising the need to develop sensitive interventions for relieving their suffering.

Meta-synthesis and evidence-based health care--a method for systematic review.

BACKGROUND: Even the systematic reviews of qualitative studies are discussed health literature, the significance of their results is not fully recognised in evidence-based practice. AIM: The aim of this article is to describe the systematic reviews of qualitative studies, metasynthesis and its process and consider the meaning of meta-synthesis in evidence-based practice. CONCLUSIONS: Meta-synthesis is a method for synthesising knowledge, for example, relating to service users' healthcare-related experiences and the factors that facilitate their involvement in their own care and commitment to a healthy lifestyle. This type of knowledge is needed in evidence-based practice. Meta-synthesis is a concept that includes several methodologies in synthesising qualitative research findings. This article focuses on meta-synthesis with meta-aggregation as a method for combining data from original studies. Following the principles of scientific rigour, systematic reviews synthesise the best available and critically appraised knowledge. The article describes the process and the role of systematic review of qualitative studies and discusses its significance for evidence-based practice when making clinical and administrative decisions, as well as more widely in social and political decision-making.

Expectations associated with the use of music in neonatal intensive care: a survey from the viewpoint of parents.

PURPOSE: The purpose of this study was to describe parents' expectations concerning the use of music in a neonatal intensive care unit (NICU) and to reveal any related background factors. DESIGN AND METHODS: A cross-sectional, descriptive, and correlational design guided a survey of 197 parents from five NICUs in Finland. RESULTS: Most parents agreed that the preferred music could have positive effects on the infants, staff, and parents in the NICU. PRACTICE IMPLICATIONS: When nurses consider making use of music in the NICU, it is also important to take into account the parents' viewpoints.

Nurses' expectations of using music for premature infants in neonatal intensive care unit.

This study aimed to describe nurses' expectations of using music for premature infants in the neonatal intensive care unit (NICU) and to find out about the related background factors. The subjects consisted of 210 Finnish nurses who were recruited from the country's five university hospitals providing premature infant care in NICU. The data were collected by validated questionnaire, and the response rate was 82%. Most nurses preferred recorded music to live music in the NICU. They expected that music would have positive effects on premature infants, parents, and staff. Few demographic and many background factors of the respondents' music-related experiences correlated significantly with the expectations concerning their preference. In conclusion, the nurses' expectations were positive regarding the use of music in the NICU, which supports evidence regarding the efficacy of music therapy for premature infants.

The effectiveness of music on pain among preterm infants in the neonatal intensive care unit: a systematic review.

REVIEW QUESTION/OBJECTIVE: The objective of this review is to synthesize the best available evidence related to the effectiveness of music as pain relieving method among preterm infants during painful procedures in the neonatal intensive care unit.Review questions are: Among preterm infants in the neonatal intensive care unit, is music effective in reducing BACKGROUND: Preterm infants (i.e. babies born at or before 37 gestational weeks) compose a patient group of the most vulnerable to pain. Infants treated in a neonatal intensive care unit (NICU) are exposed to a variety of painful procedures (e.g. heel prick, iv cannula insertion, endotracheal suctioning) and to environmental stress (e.g. noise, light). Simons et al., for example, described an average 14 +/- 4 painful procedures during the first 2 weeks of life within a period of 24 hours among 151 neonates. Many studies have shown that repeated and sustained pain can have direct and long-term consequences on the neurological and behavior-oriented development of the neonates during the rapid development phase of the central nervous system. Pain can cause detectable physiological, behavioral and hormonal changes and contribute to the altered development of the pain system during later childhood and adolescence. Instead, live music such as singing is excellent type of music when it is steady, constant, quiet, soothing and directed to the infants. Graven emphasizes that recorded sound should not replace human voice exposure in the NICU; therefore, health care providers should provide ample opportunity for the infant to hear parent's voices live, such as singing or humming, in interactions between the parent and the infant at the bedside.The AmericanAcademy of Pediatrics Committee on Environmental Health has recommended safe levels of sound, and these recommendations have been updated by an expert team of practitioners. Recommendations specify that continuous sound should not exceed an hourly equivalent sound level of 50 A-weighted decibels (dBA), and music as an auditory stimulus not exceed 75 dB in NICU. If earphones or other devices are used, sound sources should be kept at reasonable distances from the infant's ear, played for brief periods and at levels below 55 dB.Music listening can be initiated with or without the involvement of a music therapist. In this review, music can be implemented for premature infants by a music therapist or any health care providers and it will include both recorded and live music. OUTCOMES: Regardless of the type of music, several studies have investigated the short term effects of music on preterm infants, including the improvement in physiological outcomes (e.g. oxygen saturation, heart rate, respiratory rate, and blood pressure), as well as in behavioural state (e.g. crying, facial expression, body movements) and pain scores. For example, Chou et al. showed that premature infants receiving recorded music, that was the combination of womb sounds and the mother singing, with endotracheal suctioning had significantly higher oxygen saturation than when they did not receive music. Butt & Kisilewsky compared recorded music involving both the vocal and instrumental version of Brahms lullaby versus no music, and found that infants older than 31 weeks demonstrated significant reduction in heart rate, behavioral state and pain.In the study of Arnon et al. the infants receiving live music, compared with infants receiving recorded music or no music, had significantly reduced heart rate and behavioral scores during the post-intervention period. Live music comprised of a lullaby sang by the female voice with frame drum and an accompanying harp. The same music was played by a tape recorder. Live music showed significant benefits, whereas no statistically significant changes were found for the recorded music and control groups. Teckenberg-Jansson et al. indicated that music therapy combined with kangaroo care decreased the pulse, slowed down the respiration and increased the transcutaneous oxygen saturation in preterm infants. The musical instruments used were a lyre and a female human voice, which hummed or sang.There is evidence that music has also positive consequences on long-term outcomes, including length of hospitalization, weight gain, and non-nutritive sucking. For example, in the study of Caine the preterm infants received music stimulation which consisted of recorded vocal music (including lullabies and children's music) and routine auditory stimulation. Exposure to the music stimulation had many positive effects on preterm infants, such as it increased daily average weight, formula and caloric intake, and significantly reduced total hospital stays and stress behaviors for the experimental group. In addition, according to Lubetzky et al. exposure to music by Mozart significantly lowered energy expenditure among healthy preterm infants.Hartling et al. have published a systematic review on the efficacy of music for medical indicators in term and preterm neonates. Nine randomized trials (1989-2006) were included. According to the results of this review music may have positive effects on physiological parameters and behavioral states, and may reduce pain and improve oral feeding rates among the premature infants. The effects of music were evaluated during medical procedures (circumcision, heel prick) and for other indicators. In addition, Cignacco et al. conducted a systematic literature review on the efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates during the period from 1984 to 2004. According to this review there was no clear evidence that the method of music could have a pain-alleviating effect on neonates. In the Cochrane Library, one systematic review is also available up to year of 2011 concerning non-pharmacological management of infants and young children (preterm, neonate, older up to three years) during procedural pain, but this review did not consider music as an intervention.To date, there is also one meta-analysis published by Standley concerning the efficacy of music therapy for premature infants during the period from 1950 to 1999. It concluded that music was beneficial for many outcomes among the preterm infants in the NICU. However, the results of this review were limited by the poor methodological quality of the included studies, and unclear reporting on the phases of review.In our systematic review, studies published in 2000 and after will be considered for inclusion in the review. The number of the RCT's concerning the effectiveness of music among the preterm infants in NICU is especially increased during the last few years, and these studies have not included in the previous systematic reviews and meta-analysis.