The Cultural, Organisational and Contextual Processes that Might Affect the Implementation of Massage in Lebanese Neonatal Intensive Care Units
: A study Informed by Normalization Process Theory

  • Bahia Abdallah

    Student thesis: Doctoral ThesisDoctor of Philosophy


    Background: Care of premature infants is challenging for health care professionals. When the preterm infant is separated from its mother the parent-child interaction is impeded. In the last few decades, there has been increasing interest in the effectiveness of massage as an intervention to counter the negative physiological, clinical and behavioral consequences of prematurity and the neonatal intensive care unit environment.

    Aims: To establish the effectiveness of moderate pressure massage from evidence in the literature and to then explore the cultural, organisational and contextual factors that may act as facilitators and/or barriers for its future implementation in Lebanon.

    Methods: This thesis utilizes a two-step approach. Two literature reviews were undertaken to establish recent evidence on moderate pressure massage. A qualitative exploratory investigation was adopted as no articles were found that elucidated the contextual barriers and facilitators for massage implementation in the neonatal intensive care unit. The normalization process theory was used as a sensitizing framework to understand implementation issues and address the observed difficulties in implementing new interventions in clinical settings. This study was also concerned with context and culture as moderate pressure massage is not practiced in the Lebanese neonatal intensive care units. A purposive sample of Lebanese health care professionals and parents were recruited from three university hospitals with data generated through focus group discussions and observational notes. Framework analysis was used for the analysis and interpretation of the findings. The study drew on the principles and practice of ethnographic approaches.

    Findings: The findings from the two literature reviews only revealed randomized control trials that observed mostly the short-term physiological and psychological effects of moderate pressure massage. There were no studies that examined the organizational and contextual issues that need to be understood before any trial could be designed in the neonatal intensive care unit setting. The evidence from this review suggested there is a need to explore the views of health care professionals and parents on the practice of massage in the neonatal intensive care units to provide insight into the subsequent design of an intervention study that would be culturally sensitive, appropriate, and acceptable in practice. The findings from the qualitative study then revealed that despite the participants’ interest in implementing massage intervention, parents’ participation in the neonatal intensive care unit is almost absent except for breastfeeding. Participants in both groups, parents and health care professionals, highlighted the parents’ fear and anxiety. In general, nurses are in charge and parents are passive observers. Transportation difficulties, unavailability of helpful staff, and fear were reported as major barriers to parent-implemented infant moderate pressure massage; health care professionals highlighted staff attitude and resistance, workload and time constraints. Communication, gradual implementation, encouragement and support were identified by parents as potential facilitators. In comparison, having extra staff and a protocol for teaching nurses, training parents and openness to innovation were the main potential facilitators of implementation identified by health care professionals.

    Conclusion: This study helped to reveal the potential challenges of applying such a complex intervention as moderate pressure massage by the parents in the neonatal intensive care unit. Adopting infant massage in the Lebanese neonatal intensive care unit without preparation of health care professionals and parents would be premature. Good communication between parents and health care providers is a key element to facilitate early bonding and parent-infant interaction. Missing the opportunity to involve parents in neonatal intensive care unit care puts the family in a difficult situation to adapt to the new challenges after discharge. The findings of this study will advance current knowledge in understanding the factors that determine applicability, acceptability and feasibility of massage implementation in the neonatal intensive care unit setting. It will also assist and inform the design of future randomized control trials. The noramalization process theory was a valuable lens to guide the process of inquiry and to make sense of the emergent findings from this exploratory qualitative study.
    Date of Award2018
    Original languageEnglish
    SponsorsUniversity of Balamand
    SupervisorMartyn Jones (Supervisor), Heather Whitford (Supervisor) & Caroline Bradbury-Jones (Supervisor)


    • massage
    • premature infant
    • implementation
    • neonatal intensive care unit

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