Methods
A prospective, descriptive, correlational design was used. Using photographs of the abdomens of preterm infants and photographs of "staged" emesis on cloth diapers that are typically used as "burp" cloths, NICU nurses were asked to complete a survey regarding their abdominal assessment and emesis amount. Approval from the institutional review board was obtained.
A convenience sample of NICU patients was recruited in order to obtain abdominal photographs. Research personnel identified NICU patients of varying gestational ages and approached a parent for consent to photograph the infant's abdomen. A second convenience sample of nurses working in the level III NICU in a Midwestern US tertiary medical center that served as the study setting was recruited to evaluate the precision of abdominal and emesis assessments for the study. The IRB approved the study as exempt from written consent for the nurses while requiring written consent from the infants' parents. As written consent was not required for the nurses, they were sent a notice of the study's purpose and protocol, an explanation of their human subject rights, and a statement that participation in the study implied informed consent via email. These same documents were displayed in the NICU nurse's lounge and nursing stations prior to the annual, institutional proctored competency exams.
Photographs
After consent and with assistance from the bedside nurse, the lead study investigator took de-identified photographs of the infants' abdominal area during routine caregiving. For the emesis pictures, pre-measured volumes of formula (5 mL, 10 mL, etc.) were dispersed on separate white diaper clothes. A tape measure was then placed on the diaper cloths after dispersion of the varying amounts of formula to be used as a reference point within the photograph.
Procedures to Evaluate Precision
Abdominal and emesis photographs were printed on an 8x11 piece of photo paper and given a specific number. All photographs were compiled in a notebook. At the conclusion of each nurse's annual competency exams, the nurse had the opportunity to participate in the study. A poster about the study, the book of the assessment photographs, a locked ballot box, and a paper copy of the IRB documents (described above) was located in the same area as the competency examinations. Participation in the study was voluntary.
The nurses viewed the book of the de-identified abdominal assessment photographs of NICU patients and the emesis photographs. For each assessment photograph, the nurse was instructed to complete survey questions by selecting responses reflecting their perception of the photographs and consistent with their usual charting preferences. The description options of the survey questions were multiple-choice to avoid penmanship recognition errors following data collection and to be consistent with the institution's current computer documentation format. This anonymous survey also provided a space for the nurse to record his or her years of experience (categorized into 0–5 years, 5–10 years, > 10 years). When the nurses completed the survey, they placed their form into the locked ballot box available for that purpose.
The descriptive options for abdominal assessment photographs were distended, full, round, and flat which is consistent with the institution's charting. The descriptive options for emesis photographs were small, moderate, large, x1 (non-specific documentation that the infant had one episode of emesis), 5 mL, 10 mL, 15 mL and 20 mL. Nurses were able to choose more than one answer for the emesis options to remain consistent with usual charting preferences.
Statistics
Descriptive statistics and ANOVA were performed using SPSS, version 19 (SPSS Inc., Chicago, IL).