EMPIRICAL STUDIES

doi: 10.1111/j.1471-6712.2012.01076.x

Skin-to-skin care for dying preterm newborns and their

parents a phenomenological study from the perspective of
NICU nurses
Ingjerd G. Kymre RN, Pediatric Nurse (PN), MA, PhD (Student)1 and Terese Bondas RN, PHN, MNSc, LicNSc,
PhD(Professor)2
1

PHS, Center for Practical Knowledge, University of Nordland/UiN, Bod, Norway and 2Institute of Nursing and Health, University of
Nordland, Bod, Norway

Scand J Caring Sci; 2013; 27: 669676

Skin-to-skin care for dying preterm newborns and
their parents a phenomenological study from the
perspective of NICU nurses

Background: Consequences of separation between preterm

newborns and their parents have been discussed in many
aspects, thus skin-to-skin care (SSC) has become common practice in Scandinavian Neonatal Intensive Care
Units (NICUs) since the 1980s. The International workshop on Kangaroo Mother Care (KMC), 2009, recommends implementation of continuous KMC as the gold
standard pervading all medical and nursing care, based
on empirical studies and clinical guidelines and they suggest that KMC may be used during terminal care in
agreement with parents. Parents have a strong desire to
be near their child and give support and emotional comfort when the condition of the child requires it, and it
has been suggested that medical staff expect parents to
be with the neonates, and therefore, encourages them to
hold the neonate while it is dying. The practice of SSC at
the end of life has been under-researched, however.
Aim: The aim of this study, which is part of a larger
study on neonatal nursing care, was to describe the phenomenon of how nurses enact SSC for dying preterm
newborns and their parents.
Design: A phenomenological reflective life world design.
Setting and participants: A purposive sample of 18 nurses
from three Scandinavian NICUs.

Introduction
Parents have a strong desire to be near their child and
give support and emotional comfort when the condition
Correspondence to:
Ingjerd Gare Kymre, PHS, Nordland University,
8049 Bod, Norway.
E-mail: Ingjerd.gare.kymre@uin.no

Findings: The essential meaning of the phenomenon was

expressed as strong belief in the urgency of SSC in providing mutual proximity and comfort for dying preterm
newborns and their parents. The nurses act upon this
belief and upon an engagement in securing the best possible present and future experiences of being close, in
which the SSC is understood as a necessary premise in
achieving the intended optimal conditions. The findings
are elaborated in relation to previous caring and nursing
research and phenomenology.
Conclusions: Skin-to-skin care for dying preterm newborns
and their parents is the preferred caring practice among
Scandinavian NICU nurses who consider it of major
importance to facilitate proximity and comfort through
SSC when the newborn is still alive. The authors suggest
this practical knowledge from NICU nurses perspective to
be acknowledged in discussions concerning end-of-life
care for preterm newborns and their parents and we recommend more formal establishment of this practice. Further research is needed on parents experiences of skin-to
skin caring in this vulnerable end of life situation of
being with their dying newborn.
Keywords: Skin-to-skin care, end-of-life care, neonatal
nursing, dying preterm newborns, mutual experience,
proximity in dying, phenomenology, reflective lifeworld
research.
Submitted 30 March 2012, Accepted 31 July 2012

of the child requires it (1). Consequences of separation

between preterm newborns and parents have been discussed in many aspects, thus skin-to-skin care (SSC) has
become common practice in Scandinavian Neonatal
Intensive Care Units (NICUs) since the 1980s. Positive
effects and benefits have been documented through
empirical studies worldwide since the first introductions
of the practice as Kangaroo Mother Care (KMC), inspired
by the Instituto Materno Infantil in Colombia after 1978

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I.G. Kymre, T. Bondas

(27). Its main benefits are physiological stabilization,

thermal regulation and stimulation of maternal lactation
(2). Intermittent SSC, which means limited sessions, is
the most implemented method in affluent settings (5).
An expert group of the International Network, from the
7th International Workshop on KMC, 2009, recommends
implementation of continuous KMC as the gold standard
pervading all medical and nursing care, based on empirical studies and clinical guidelines (5). Decreased pain
response during painful procedures, positive effects on
sleep and improved brain maturation are documented
effects of KMC (5, 7). Other outcomes are psychosocial
aspects like improved parentinfant interaction (5). The
network report suggests that KMC may be used during
terminal care in agreement with parents (5).
A Norwegian study found that care offered to dying
infants and their families changed significantly in many
respects from 19871988 to 19971998 (8), which
reflected that parents were increasingly more present at
the time of the childs death and involved in the process
to forgo life support. An increase in the proportion of
dying infants for whom withholding or withdrawal of life
support preceded their death was found. An American
study from the period 1999 to 2008 found that the primary mode of death in their NICU was the withdrawal of
life-sustaining support (9). Those findings may represent
a trend, and exemplify elements related to the background of this study context, which concerns situations
in NICUs where medical and nursing staff and the parents realise that the preterm newborns condition is not
compatible with life or a decision has been made to stop
life-supporting treatment.
When the neonate is dying, medical staff expected parents to be with the baby, and encourage the parents to
hold him/her (10). According to Armentrout (11), parents have an intense need to carry their deceased newborn with them as they move forward with their lives,
and she emphasised the importance of providing parents
with an opportunity to spend time with their infant as a
member of the family, without all the tubes and wires.
However, studies concerning the phenomenon of practicing SSC for dying preterm newborns and their parents
are limited.

Aim
The aim of this study, which is part of a larger study on
neonatal nursing care, was to describe the phenomenon
of how nurses enact SSC for dying preterm newborns
and their parents.

Method
The approach that was chosen to this study is reflective
lifeworld research, as developed by Dahlberg, Dahlberg

and Nystrom (12), which in its turn is based on the phenomenological philosophy of Husserl and Merleau-Ponty.
The approach assumes an open attitude to the phenomenon, in this case the nurses relationship to SSC in dying.
The aim of lifeworld research is to describe and elucidate
the lived world in a way that expands our understanding
of human being and human experience, and the clarification of meaning as it is given (12). Here, it means articulating what is at stake for nurses when they encourage
SSC between dying preterm newborns and their parents.
The lifeworld refers to the world as experienced. Within
this approach, it is central to illuminate the essence or
structure of meanings that characterises the phenomenon
(13). According to Dahlberg, the essences are their phenomena and the phenomena are their essences. The
research challenge for this study has been to illuminate
the essential structure from this particular context of SSC
to find the style of this particular phenomenon.

Participants
A purposive sample of 18 nurses from three NICUs in
Sweden, Denmark and Norway, (six from each) were
interviewed at their workplace. They were selected by unit
leaders based on the criteria that they were willing to participate and were available to be interviewed during two
selected days and afternoons. Nurses who had been working in a NICU for more than 5 years were preferred. All
available nurses were female, though this was not a criterion. The Swedish nurses had been practicing 324 years
(median 13) in a NICU, the Norwegian; 422 years (median 11) and the Danish; 722 years (median 12). 12 nurses
had a higher degree or education in paediatric, neonatal,
intensive, surgery or public health nursing, NIDCAP-education or other specialized courses. NICUs were selected
because they showed a commitment, through homepages
or in other ways, to SSC as a part of their practice. The
three were all large units. Data collection in three different
countries was meant to possibly represent variations of
experience and meaning.

Interviews
The nurses were asked to describe their lived experiences
concerning the phenomenon that was chosen (12, 14).
The first author carried out the interviews. 17 of the 18
participants answered yes to the opening question: Have
you ever brought a preterm newborn to a parents body
for SSC when you knew it was going to die? The last
participant had been present when such situations took
place. To find out what they considered important, the
next question was: Can you tell me about one or several
such situations? Probing questions were asked to obtain
details, and to clarify unclear statements. The participants
could more or less in detail remember situations of caring

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A phenomenological study from the perspective of NICU nurses

for parents and newborns within this context. The interviews took place in November and December 2009, and
the digitally recorded material was transcribed verbatim
during spring 2010. None of the authors had any connection to the selected NICUs.

Ethical considerations
This study was approved by the Regional Ethical Committee (15) and the Norwegian Social Science Data Services (16), which reviews projects based on guidelines for
research ethics. The research is in line with the ethical
guidelines for nursing research in the Nordic countries
(17). The material was stored according to the guidelines
of the Norwegian National Committee for Research Ethics in the Social Sciences and the humanities, NESH (18).
Permission to carry out the study was obtained from the
head nurses or physician of the hospital units. The nurses
had received a letter that introduced them to the aim of
the interview. Permission to record the interviews was
given from each participant, and participants were
assured that the information would be treated confidentially. The participants were informed about their right to
withdraw from the study at any time.

Analysis
In line with Dahlberg et al. (12), the entire descriptions
were initially read to get a sense of a whole. Preunderstanding, including personal beliefs and theory drawn
from personal experience with the phenomenon was set
aside in the sense of bridling, to allow the essential
meaning of the nurses utterances to manifest themselves. The main point of bridling is to bring us closer to
the meaning of the phenomenon without limiting the
research openness (12).
The descriptions were divided into units of meanings,
which sometimes made it necessary to break up significant shifts in meaning. Clusters of descriptions were analysed and organized, and constitutive elements that
described various meanings to the phenomenon were
identified. A new whole was written to emphasise the
essence of the phenomenon, having in mind that according to Dahlberg (13), describing essences is a clarification
of meaning as it is given, and any meaning that we discover belongs to the phenomenon. The phenomenon
being analysed was SSC for dying preterm newborns and
their parents, and the research process led to a new written understanding of the phenomenons essential meaning of parts and whole.

Findings
The various and rich descriptions of the phenomenon
indicated that independent of three different participating

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Scandinavian countries, the essential meaning of the

phenomenon was expressed as a strong belief in the
urgency of SSC in providing mutual proximity and comfort for dying preterm newborns and their parents. The
nurses act upon this belief and upon an engagement in
securing the best possible present and future experiences
of being close, in which the SSC is the preferred caring
practice and is understood as a necessary premise in
achieving the intended optimal conditions for mutuality.
The notion of loss was connected to an importance for
parents of having been close to or with the preterm newborn for being able to articulate and acknowledge the
meaning of their loss. To provide this aspect, tubes and
wires were removed after the transfer to the parents body,
after establishing skin-to-skin contact, sometimes very
quickly because of the newborns poor medical condition.

Expressing strong belief

Strong belief was expressed through the ways nurses
described how they reasoned, acted and gave SSC priority. The notion I believe was used, following gestures
underlining strong belief and engagement. Furthermore,
this strong belief was expressed as a commitment in the
context of caring rather than in the context of treatment:
I believe it is good for the newborns because I have seen
well-being in preterm newborns receiving SSC so many
times, exemplifies how belief is expressed, as well as I
just believe instinctively that dying newborns should not
be alone, but in the arms. Alone means in the incubator
or not close to another body. Words indicating a belief in
what are the best possible ways to act were used generally through the descriptions. She laid skin to skin constantly through two days and nights because we thought
that every moment was her last and We have taken out
babies from the incubator because we know there is no
way back, are examples where an explanation justified
with a because indicates an implicit belief in facilitating
SSC as the right thing to do.

Realizing urgency in transferring, and limited, valuable time

for being with
A quotation that exemplifies how a decision to facilitate
SSC is made without dwelling is, Sometimes I grasp the
urgency of parents holding the newborn when it is still
moving. When it is realised that the newborn is going to
die, or a decision is made to stop life-supporting treatment, there is no doubt among the nurses asked about
transferring the newborn close to its parents body, skin
to skin. The preterm newborn should have the opportunity to be with its parents before passing away, a nurse
claimed with an extra emphasis on the notion should.
Urgency was expressed in terms of giving SSC priority
by describing how the tracheal tube is kept until the

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I.G. Kymre, T. Bondas

dying newborn is placed against a parents bare chest to

secure that the moment of dying takes place there when
the newborn is still alive. Pulse frequency and other perceptual parameters sometimes indicate limited time and
that the newborn will die very soon, and several nurses
said, We always facilitate SSC if we know the newborn
will not survive. In contrast to keeping the tracheal tube,
examples of removing it before transferring from the
incubator were described as stressful and less optimal;
The newborn died at once, so it was more dramatic and
shocking than we had expected, they should have had
more time together.
A concern about SSC while keeping the newborn alive
beyond a necessary hospital transfer was described, as
well as the concern of not achieving it, and it was
expressed in the following:
Together with the transport, team we made a decision not to transfer a newborn to another hospital
nearby, because if we did he would have been separated from his parents. He would have been placed
into a transport incubator, and if so, the medical staff
would have the responsibility to keep him alive during the time of the transport and you cannot do
that, so there was no prospect of moving him. We
let him lie skin to skin, and he took his final breath
on his mothers chest.
The matter of dignity for the dying newborns was
raised as challenging in regard to simultaneous urgency
of the situation. This manifested itself in terms of a
rapid transfer from the incubator to the parents body
when the child is close to death. This included concerns
about the newborns feeling uncomfortable, concerns
that were identified in several descriptions. The transfer
became a problem to which nurses needed to attend by
being sensitive and careful in the practical act of transferring, in that SSC was still given priority. Occasionally, the newborns do not die very quickly, but nurses
still characterize time with their parents as limited. The
time of being with, skin to skin, was also characterized
as valuable time, whether they managed to have this
time or not.

Expressing engagement
An engagement in skin-to-skin caring was expressed as
double-oriented from the nurses perspective. The
descriptions involved how nurses imagined the newborns experiences, consciousness and feelings, together
with observing and understanding physiological parameters. Actually, I do not know how conscious the newborn is, or about its sensory experience, was expressed
by one nurse, and another said,
Because he was very ill, I am uncertain of what he
was sensing. I think it depends on the various physical condition and medications, if they are conscious

or in a doze, but I believe that the skin-to-skin contact is good for the newborns.
A projection of dying newborns having a feeling of being
scared was expressed: I think that skin-to-skin contact
will help the newborn in not feeling scared of experiencing the lack of air.
An engagement with how parents experience the situation was as an example expressed by a nurses reflections about how difficult it must be not to have had the
chance to hold your newborn close to your body, I
think it is a deep-seated need in women to feel their
baby against their skin, she said.

Facilitating mutual proximity and comfort

A lived particular example of the SSC in a situation of
dying was this; He was lying naked in her arms in that
the mother could see his face, he was just wearing a diaper, she lay in a bed and she held him into her skin
against her breast. Then we removed the tracheal tube.
Experiencing closeness, touch and comfort is emphasized as an aim in terms of both giving and receiving
between the dying newborn and its parents. A receiving
dimension was exemplified by quotations such as A
newborn should not have to die alone, but feel the proximity, and The newborn receives proximity the short
time it is here Another said, Both the parents and the
newborn should get the opportunity to feel the proximity
even if there is an awful incident going on
In addition, a giving dimension was described as,
There is no other way that you can transmit that you
are close, more than through skin-to-skin contact. and
They were with him, and could follow him on his way,
in that he was not alone.
Skin-to-skin care was also expressed as a way to prevent suffering. A nurse said that she hoped that the baby
would experience comfort just for a short while to let
the baby perceive safety in hearing the mothers heart
and voice, and further, as long as the baby is able to
feel the mothers heart beat, he or she shall do so, I
think. Another description expressed the quality of SSC
as Contact with skin is different from contact with fabrics, and feeling comfort skin to skin, noted some,
included absence of pain and hunger.
A few experiences exemplified exceptions from the
norm of the mutual dimension of closeness in that the
parents were not present, and nurses were with the newborn in the dying process by holding and touching the
baby. They described themselves sitting with the newborn in their arms, to let the parents have some sleep,
pointing to the importance of not leaving the newborn
alone in this condition, under any circumstances. A
nurse said, It was important for the parents that the
newborn had skin-to-skin contact continuously, so I sat
with their dying newborn skin to skin against my arm.

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She had not told anybody, but it made her determined
afterwards never to let a newborn die without SSC, and
this was something she encouraged other nurses to practise as well. Another example concerned a newborn boy
who died suddenly, whose parents could not immediately be contacted by the medical staff, so that they could
get there when he was still alive. The nurse was glad to
tell them that she held his hand as long as he was alive,
because that was something, even if it was not optimal.
The thought of letting a newborn die alone in the incubator gave her a feeling of emptiness.

Securing the best possible present and future experiences by

skin-to-skin care
The importance of securing that the parents had felt that
the baby was real was underlined and the statement of
the newborn as having been was connected to the
touch of a living body. One nurse said vividly:
When the parents have got the baby on their bare
skin on the chest, and when they have perceived his
presence, it is not something unreal, because he
actually was here (puts her hand on to her own
chest). I think it is an important matter, that they
have held him here.
This quotation, underlined by using a gesture, exemplifies that the experience of something real and actually
felt was connected to future experiences through
remembering.
The nurses used notions connected to the context of
SSC in how they understood a parents perspective of
bonding, accepting loss, adopting emotionally, the end as
something beautiful, feeling closeness, following him on
his way, peacefulness and crossing a border. Crossing a
border meant doing something not easily done or with
which one is not familiar.
I believe that it is meaningful that they get something
good to carry with them, something to remember. They
can say that they have lost a child, one nurse said. Both
she and others referred to human touch skin to skin and
to the act of holding closely. This was often connected to
the idea of providing the best possible memories to look
back on. When the nurses reflected on how they imagined the parents remembering, they mentioned both the
experience of holding close and the experience of the
picture of the newborn.
Collecting physical objects was described, while nurses
often help parents take photographs, footprints and
sometimes tiny locks of the babys hair to provide physical memories for remembering their newborn. Some
described placing the newborns body in a position that
makes it possible for the parent to see the face without
tube and tape, maybe for the first time ever. Remembering a nice and peaceful picture of the newborn was
emphasised, and described in terms of the look on the

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babies face, skin colour, clean blankets and absence of

medical equipment covering the body. To provide time to
hold the baby when it is still warm was emphasised as
something that could give parents a better experience to
remember than the touch of a cold body.
In describing urgent situations, the environmental conditions were generally not focused on as an important
matter. In contrast, one of the nurses had noticed the
impersonal room, but she got the impression that the
parents did not notice the environment, because they
focused on the holding experience. According to participants, there is an aspiration towards as much privacy as
the situation allows, even to the extent of transferring
other patients.

Persuading the parents to hold their dying newborn skin to

skin
The nurses described deviations in the experience of
what parents are able to cope with in their grief in losing
their newborn baby. They pointed to the importance of
careful approach to how they facilitate closeness. We
cannot push them too hard, was said. The very first SSC
is sometimes a threshold to cope with, especially if the
newborn is critically ill or dying. If parents have not held
the living baby, there is often more resistance to hold the
dead baby. One nurse said, I will not push them if they
wont, but I will always try to persuade them to hold the
child close.
Events concerning parents who do not want to touch
or hold the dying newborn were among the descriptions.
Even when we meet parents who decline to hold the
deceased newborn, we try to convince them, a nurse
said. She continued, We seldom meet parents who dont
want to, but it makes us concerned. Descriptions
referred to declining and showing fear in parents, and
how nurses meet this reaction with being concerned, and
if parents decline being close to the dying newborns,
nurses sometimes try to persuade them to hold them skin
to skin. But still, a few parents choose to keep aloof from
their dying newborn, and nurses save footprints, hairlocks and pictures for them. However, the common experience among the participating nurses was that parents
are thankful for being helped to cross the threshold of
getting close to the child they were about to lose.

Discussion
The nurses strong belief in the urgency of SSC in providing mutual proximity and comfort for dying preterm
newborns and their parents, expresses the essential
meaning of the phenomenon.
Essential meaning is built upon constituents concerning both the aspect of how the phenomenon was
focused, as well as the aspect of what the nurses focused

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on that belongs to the phenomenon. How the phenomenon is focused was expressed through strong belief and
engagement. What they focused on was expressed as
facilitating mutual proximity, securing the best possible
present and future experiences by SSC, and persuading
the parents to hold their dying newborn child skin to
skin.
This study is limited to research on how nurses act in
this context and therefore their perspective was illuminated. According to Bondas (14), phenomenological
research has the potential to challenge previous knowledge and practice in postpartum care and to develop new
caring science knowledge, evident for clinical caring practice. How can the essential meaning from NICU nurses
caring practices in this study be elaborated within neonatal science, caring science and a phenomenological
approach? This works contribution will be illuminated in
the following.
In his Introduction to Phenomenology, Sokolowski
(19) wrote that the core doctrine is the teaching that
every act of consciousness we perform and every experience that we have is intentional, which in this discussion
is understood in terms of how meanings are something
essential intended. From this understanding, the constituents that make the structural essence of this phenomenon indicate that nurses are intending mutual closeness
and comfort both as a present and a future experience.
In recognizing the double caring focus by SSC in this
study, the relational aspect was emphasised. Expressions
of an urgent importance of facilitating both a giving and
a receiving dimension of the SSC emphasize nurses
intentions to facilitate a mutual experience in parents
and dying preterm newborns in NICUs.
In 1959, Maurice Merleau-Ponty (20) wrote about
Chiasm, as opposed to For the other, meaning that
there is not only a me-other rivalry, but a co-functioning
relationship. Merleau-Pontys concept of flesh and chiasm captures the reciprocity of the motherinfant relationship, according to Wynn (21). She highlights those
thoughts by maintaining that the holding relationship
becomes reversible, in which mother and infant are holding and held and the touch is about touching and being
touched, and that they both actively constitute the relationship. The infant plays a dynamic part in holding.
Therefore, holding and being held and touching and
being touched, constitute a chiasmic relationship. Wynn
contends that mothering is a bodily practice, an idea that
is also supported by Broeder (22), who asks for a better
understanding for intuitive bodily care-giving and connectedness felt by mothers at first holding their preterm
newborns. Broeder was concerned with the psychical
health of mothers, based on the profound aching and loss
that the mothers feel while separated from their newborn, unable to physically hold it. The focus that nurses
in this study had on the importance of SSC and their

engaged relation to the newborns feelings, shows an

understanding of the newborn as conscious in some way,
and not being left alone seems to be equivalent to physical contact and comfort.
Development of mutual interaction and affinity
between mothers and healthy full-term newborns was
also emphasised as essential in a study of mothers experiences of SSC the first days after birth (23). That study
illustrates a view on SSC that illuminates both similar
and contrasting knowledge to this study. The understanding of mutuality is common as essential, but the nursing
perspective, the context and the constituents differs,
which indicate different phenomena where the intending
acts and objects differ, as does the contextual variation.
Both studies emphasise the double caring focus on parent
and child as a unity in SSC.
Facilitating SSC is given priority in this study, but
sometimes nurses were challenged by parents who
decline closeness to their dying neonates. Fegran found
that nurses gradually master technical and instrumental
tasks, but many of the nurses in that study found interaction with parents to be much more challenging and
demanding (24). Parents of extremely preterm newborns
experienced the immediacy with which decisions had to
be made, particularly whether to see and hold the newborn before death, according to Kavenaugh (25), when
she suggested in 1997 that parents may not be prepared
emotionally to hold the newborn at the actual time of
death. Thus, in 1998, Lundqvist and Nilstun (26)
reported that most of the nurses in a study were inclined
to give priority to the principle of the beneficence of seeing, touching and holding the dead or dying newborn.
Some nurses experienced a personal failure if they were
unable to persuade the mothers to hold their dead baby.
In a 2002 study, Lundqvist, Nilsstun and Dykes (27)
found that most of the mothers felt from the bottom of
their hearts that they wanted to hold their still-living
baby, but did not have the courage to, because of fear.
Persuasion by the staff was found to be supportive, and
healthcare professionals expressed the opinion that it was
important for the mothers to hold their baby during the
dying process. In Bondas 2005 study (28), new mothers
experience that they are with child, even when the child
is not momentarily there or they have lost the baby early
in the pregnancy. Women who did not have the baby on
their chest after birth expressed disappointment and sadness years afterwards, according to Lundgren et al. (29).
Moro et al. (30) suggest that a majority of parents may
want to be a part of the dying process and found solace
in being able to hold their baby before and after death,
but a minority preferred to have limited or no involvement. This study, however, illuminates that strong belief
in nurses at the participating NICUs is present in how the
intended essence of being with is expressed through the
practical act of persuading or influencing the parents.

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A phenomenological study from the perspective of NICU nurses

Skin-to-skin care in dying was not discussed in the
studies mentioned above, which may indicate a changing
practice of holding dying preterm newborns parallel to
the developing use of SSC in general. Therefore strong
belief in practical embedded knowing in this context in
all likelihood is influenced by paradigmatic and historical
science and habits. According to Charpak and Ruiz (2),
KMC has brought to reality a new paradigm in the care
of preterm infants, to avoid motherinfant separation
from the very beginning of extra-uterine life. The discussion places this study historically in line with studies concerning implementation of SSC or KMC 24 hours a day
in NICUs. Thus, SSC in a situation of dying is, according
to this study, a kind of intervention built on strong belief
in what is the right thing to do, where the only obstacle
is occasional reluctance of some parents to participate.
From the nurses perspective, however, this participation
is necessary in making the phenomenon a meaning-giving activity, and need to be encouraged.
This knowledge about the phenomenon indicates that
SSC is not only a way to proceed when a preterm newborn is dying, but a necessary premise in achieving the
intended optimal conditions for mutuality.

Conclusions and implications for practice

Skin-to-skin care for dying preterm newborns and their
parents is the preferred caring practice, understood as a
necessary premise in achieving optimal conditions for
mutuality. Therefore, it is of major importance to facilitate proximity and comfort through SSC when the newborn is still alive.
A strong belief in its urgency indicates that SSC in the
situation of dying has become embedded in caring practice among Scandinavian NICU nurses and belongs to a
new paradigm in the care of preterm infants, which is
committed to avoiding motherinfant separation from
the very beginning. A double caring focus on the mutual
experience of skin-to-skin contact in the parentnewborn
relationship is acknowledged and respected for its human
values, where the dying preterm newborn is seen as an
active as well as a passive agent.

References
1 Wigert H, Berg M, Hellstrom A-L.
Parental presence when their child is
in neonatal intensive care. Scand J
Caring Sci 2010; 24: 13946.
2 Charpak N, Gabriel Ruiz J. Kangaroo
mother care: past, present and
future, editorial. Curr Womens Health
Rev 2011; 7: 22731.
3 World Health Organization. Kangaroo Mother Care, a Practical Guide.

675

The authors suggest this practical knowledge from

NICU nurses perspective to be acknowledged in discussions concerning end-of-life care for preterm newborns
and their parents and we recommend more formal establishment of this practice.
Further research is needed on the experience of parents in relation to SSC in this vulnerable situation of
being with their dying newborn.

Acknowledgements
The authors would like to thank the participants for
helping us undertake this study. We want to thank Professor and philosopher James McGuirk for his contributing reflections and supervision, and Associate Professor
Jessica Allen Hansen for revising the English text.

Conflict of interest statement

The authors declare that there is no conflict of interest.

Author contributions
Both authors contributed to this article. The idea of the
study, data collection, preliminary analysis work and
drafting of the manuscript was performed by PhD student
Ingjerd Gare Kymre. Professor Terese Bondas regularly
met with Ingjerd Gare Kymre for reflection and supervision and contributed to critical revision.

Ethical approval
The Regional Ethical Committee, REK Nord, who found
further proposal of the study not obliged. Document reference; 2009/106-18. The Norwegian Social Science Data
Services, NSD, http://www.nsd.uib.no/ which reviews
projects based on guidelines for research ethics registered
it with the project number: 22199.

Funding
Funding was not obtained.

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