Attitudes and Perceptions of Nurses Regarding Early Communication Intervention

Although nurses play a vital role during Early Co111municarion Intervention with infants and toddlers 0-2 years, limired research has been conducted regarding this role. The purpose of rhe current study was to determ.ine the attitudes and perceptions of nurses regarding Early Communication Intervention. Sixty nurses working in paediatric wards and neonaral intensive care units i11 hospitals in Pretoria, acted as responden1s. A descriptive survey design was used and a questionnaire was completed by the respondenr.s. The results indicated that the respondents perceived the role of the nurse in Early Communication /11terventio11 to be important. Areas of insufficient knowledge of Jhe respondents were also ide111ij1ed. Enhanced cooperation between the nurse and speech-language rherapist is viewed as essential. In-service training and sharing of information is recommended to improve 1he quality of Early Communication Intervention. services supplied ro high risk infants and roddlers. in order to ensure optimal communication developrnent in the infant and toddler 0-24 nwnths.


INTRODUCTION
Early Communication Intervention refers to the assessment and treatment provided to fami lies and their children below the age of three years, who demonstrate, or are at risk for either a disability or a delay involving communication, language, speech or oral-motor behaviour (ASHA, 1989).
According to Rossetti ( 1990) children who are at risk for a communication delay or disability are viewed as representing established risk factors, such as diagnosed medical conditions (e.g. Down syndrome), biological risk factors (e.g. low birth weight, prematurity), or environmental risk factors (e.g. adolescent mothers, parents who are substance abusers).
These factors may, either singly, or in combination, result in developmental difficulties or may interfere with normal development (ASHA, 1989).
A primary health care model has been proposed in South Africa to meet the needs of the community with priority given to the most vulnerable groups, i.e. children. This model emphasizes full community participation and team work as central components of services rendered. Early Communication Intervention provides services to children 16 who are at-1isk for developing communication delays or disabilities and is viewed as an effective strategy in the secondary prevention of communication disorders (Rossetti, 1990). It improves the prognosis of the infant and family, leads to the development of the child's maximum potential and can averr potential problems. Early Communication Intervention involves educating, training, supporting and thus empowering fami lies of high risk infants and toddlers and fits into the framework of the primary health care model envisaged for South Africa.
In the USA, Public Law (P.L.) 99-457 ( 198699-457 ( , in Rossetti, 1990 mandates services to disabled infants and toddlers (birth to 3 years of age) and theirfarnilies. This law specifically states Lhat services to lhese infants and toddlers are provided by multidisciplinary teams composed of qualified personnel (Weitzner-Lin, Chambers & Siepierski, 1994). Increased research and interest in early intervention programmes has led to wide spread implementation of early intervention. As more states and countries embark on providing earl y intervention, new roles continue to emerge in various disciplines (Dunn. van Kleeck & Rossetti, 1993). One such new role is the active involvement of nurses in Early Communication Intervention.
Parents as well as nurses are the primary caregivers during hospitalization or infants and toddlers and have an important role LO play in Earl y Communication lnter-vention (Rossetti. 1990(Rossetti. , 1996. The nurse is in close communicative interaction with the hospitalized infant and toddler. Due to longer hospitalization periods that at-risk infants and toddlers are often exposed to. the nurse has the unique opportunity to observe the communication skills of infants and toddlers who are at risk for developing a communication delay or disability. N urses can ser ve as an important link in the identification and referrals of infants and toddlers to the speech-language therapist and play a significant role in the language stimulation of hospitalized infants. T o be adequately prepared for their role in Early Communication Intervention, nurses should have core knowledge regarding communication disord ers and how these disorders are treated (Shanks, 1983).
Effecti ve communication is fundamental to all aspects of human functioning. The development of communication begins in infancy long before the emergence of first words. Language is a necessary skill for success in social, emotional, and academic development (Hulit & H oward, 1993). A ny delay or disorder that influences a young child's communication development is l ikely to have a significant effect on that child's later social. personal and academic life (Rossetti. 1996). Infants and toddlers who display disabilities or are at-risk for developing a communication disorder should be enroled in Early Communication Intervention programmes as a secondary prevention measure to allow the child to develop his/her maximum potential.
The aim of Earl y Communication Intervention is described as maximizing the child 's development, preventing later secondary disabilities, supporting families and providing cos t-effective services (Bricker. 1989). To reach those obj ectives, comprehensive services, continuous education and therapy, family involvement. and a variety of services must be deli vered to meet the ch ild and family's needs (Bricker. Bailey& Bruder, 1984). Toexpectanyoneagency to ser vice all the needs of the family and child is unrealistic. Professionals operating alone tend to develop a very narrow view and thus miss important aspects of developmental delay by interpreting observed behaviour from a limited professional vantage point (Rossetti. 1990). It is therefore important to establish a team-approach, where a vari ety of professionals cooperate to deli ver comprehensive services to the child and family.
In a team-approach, each member works with a greater awareness of what others are doing, a greater degree of coordination and integration of services can be delivered and professionals share responsibi I ities, working towards a common goal (Rossetti, 1990).
One of the most effecti ve ways that team members can improve their ability to function more effecti vely is to understand the role that they and others fulfil in a team. To achieve a team-approach, members should commit to teaching and learning from one another, and must assume interchangeable roles and responsibilities (Briggs, 1993).
The care of high-risk infants and toddlers is shared among many health care professionals but two key team members in Early Communication Intervention are nurses and speechlanguage therapists.

HEALTH SA GESONDHEID Vol. 2 No. 2 -1997
The importance o f the role of nurses is based on the following: the developmentally disabled infant and toddler often have chronic health problems, some of which will necessitate repeated hospitalization (Copeland & Kimmel. 1989), resulting in separation from caregivers, impairing both attachment and associated normal communication development (Sparks, 1989).
Nurses share primary caregiving with parents during hospitalization (Rossetti, 1990) and can influence social development of at-risk infants and toddlers as a great deal of the hospitalized infant and toddler's time is spent with the nurse (Miller & Holditch-Davis, 1992). Nurses also serve as role-models for the parents and affect the amount of time that parents spend with infants and toddlers by encouraging or discouraging visitation (Miller & Hold itch -Davis. 1992). Nurses know when infants and toddlers are likely to be in an alert state and can use a wide range of opportunities to provide language stimulation Lo the hospitalized infants. Finally, according to Jacobsen and Shu bat ( 199 1) nurses' implementation of communication techniques will reinforce parents' skills in this regard.
The speech-language therapist has the experti se and primary responsibility in Early Communication lnLerven tion for identifying, assessing, diagnosing and treating communication delays or disabilities (e.g. recepti ve and expressive language) and oral-motor disabilities (eg. feeding and swallowing processes). Consultation w ith other professionals in providing Early Communication Intervention services is another one of the speech-language therapists' roles. (ASHA, 1989). Parents are provided with informat ion on normal communication development and families are helped to adjust to caring for their infant. The speechlanguage therapist also trains parents to communicate with their at-risk infant and toddler. Feeding assistance may be provided as well as modification of the infant and toddler· s environment to allow for optimal communication (Jacobsen & Shubat. 1991 ). The speech-language therapist provides and evaluates the effectiveness of Early Communication Intervention, modifies a particular programme and is responsible for enhancing public awareness regarding speech. language and oral-motor problems of at-risk infants and toddlers (AS HA . 1989).
According to the above description of the roles of nurses and speech-language therapists in Early Communication Lntervention, a good foundation exists for the development of a collaborative relationship between these two disciplines. where the emphasis is placed on shared goals, that will serve in the infants' and toddlers' best interests. Clearly both the nurse and speech-language therapist have complimentary roles Lo play in Early Communication lntervention.
Although nurses play a vital role during Early Communication Intervention. limited research has been conducted internationally regarding perceptions of their role.
The purpose of this study was to detem1ine the attitudes and perceptions of nurses regarding Early Communication Inter vention . ll was hoped that information could be utilized to initiate and establish effective team work to the mutual benefit of infants and toddlers who are at-risk for communication disorders and to the participating team members.

Aims:
The following research questions were posed and served as the aims of the study: What are the attitudes and perceptions of nurses working in in-patient, high care contexts regarding the roles of the speech-language therapist and the nurse during Early Communication Intervention?
What is nurses' knowledge of the factors and conditions contributing to communication delays or disabilities in infants and toddlers?
Do nurses have adequate knowledge to identi fy communication de lays and disabilities in in fants and toddlers 0-24 months, and do they have adequate knowledge regarding the effects of a communication disorder on other developmental areas?
What are nurses' perceptions and attitudes of communication interaction with infants and toddlers in their care?
What are nurses' attitudes regardi ng a team-approach during Early Communication Intervention?
Do nurses require additional information on Earl y Communication Intervention?

Research Design
This study employed a descriptive survey design (Bless & Achola, 1990) to examine the attitudes and perceptions of nurses regarding Early Communication Intervention. A questionnaire was compiled to gather information.

Subjects
A target population of nurses working in paediatric wards and neonatal intensive care units was used for this study. Ten hospitals in Pretoria were contacted telephonically and permission was requested to distri bute the questionnaires to paediatric nursing staff members. Staff in eight of these ten hospitals were prepared to act as respondents of the questionnaire. Sixty of the one hundred questionnaires that were distri buted, were completed and utilized in the study. This high return rate is attributed to the fact that the questionnaires were delivered and collected personally (Bless & Achola, 1990). Table I provides the demographic characteristics of the respondents.

18
According to Table I the majority of the respondents were di ploma graduates, worked in children's wards and were permanently e mployed by private hospitals.

Instrument
A questionnaire was compiled with the aim of determining the attitudes and perceptions of nurses regarding earl y communication intervention with at-risk infants and toddlers aged 0-24 months. Tbe sample group of 0-24 months was selected as Early CommunicaLion Intervention has been proven to be more effective the earlier it is initiated (Rossetti, 1996). The questionnaire was accompanied by a cover letter to the respondents in which the general purpose of the survey was explained, their cooperation was requested and their anonymity was ensured.
The questionnaire was developed with carefu l consideration of those issues that are most relevant to Earl y Communication lntervention. The content areas and items were selected based on a thorough review of the literature and on knowledge and experiences that the authors fe lt were important to have in order L o function optimally as a nurse on an Earl y Communication Intervention team.
The questionnaire itself consisted of six content areas. Those content areas that the survey addressed were: ( I) role of the nurse, and of the speech-language pathologist: (2) factors and conditions contributing to earl y communication delays or disabilities; (3) earl y identification of communication disorders; (4) communication interaction with infants and toddlers; (5) team-approach: (6) requests for additional information.
The questionnaire contained different types of close-ended questions as these are regarded as simple and easy to record and score, improving the efficacy and reliability of results (Bless & Achola, 1990). Close-ended questions, however, also have certain disadvantages (e.g. guessing, selection of logical answers, clerical errors). The close-ended type of question was selected due to the respondents extremely busy schedule and the limitations thereof were born in mind in compiling the questionnaire (Bless & Achola. 1990).

Data Collection Procedure
One hundred questionnaires were deli vered lo the hospitals by the researchers. The aim of the survey was discussed with the nurses in charge of the paediatric and neonatal intensive care units targeted, and they were requested to distribute the questionnaires to their colleagues. In order to limit possible bias, it was agreed that respondents would not con-oborate with each other in completing the questionnaire and that completed questionnaires would not be open to scrutiny of others. A return date was determined and the researchers personally collected the completed questionnaires.

Data Analysis and Processing
Sixty questionnaires were returned and included in the data analysis. The data obtained from the questionnaire was encoded according to a computer coding system devised for the study. The data was described quantitatively by providing each answer to a question in the form of cumulative frequencies which were then converted to percentages of responses to each question. A simple frequency distribution of the answers to each question was used to present the data (Dane, 1990).

RESULTS AND DISCUSSION
The results are presented according to the research questions posed.

Attitudes and perceptions regarding the roles of the nurse and speech-language therapist during early communication intervention.
According to Figures I and 2 the respondents rate both the nurse and the speech-language therapist as important team members during Early Communication intervention. Figure I illustrates that the respondents agreed strongly that nurses could identify communication problems (93%). could cope with feedi ng problems (85%) and should provide information to and be supportive of parents (78%). According to figure 2 the respondents felt that the speechlanguage therapist could detect a hearing Joss earl y (94%). assess oral-motor functioning (92%). provide stimulation (98%), facilitate the development of communication skills (9 1%) and determine the need for intervention (90%). However, uncertainty exists regarding the specific roles of these professionals e.g. the role of the nurse during Early Communication Intervention, the role of the speechlanguage therapist during feedi ng. The findings indicate a need for a clearer role differentiation between that of the nurse and the speech-language therapist during early communication intervention. help parents to communicate effectively with their at-risk infants and toddlers. The respondents did not appear to realize the importance of early stimulation and the need to act as adequate role-models for optimal communication development. According to Miller and Holditch-Davis ( 1992) nurses set the tone for parents' interactions with their hospitalized infants. Nurses help parents lo read and to respond to infant cues and help them to develop effective strategies for soothing and socializing with their infants (Gardner & Hagedorn, 1992).
The respondents were also not sufficientl y aware of the role that the speech-language therapist plays during feeding (48%) (see Figure 2). The find ings therefore support the need for closer networking between nurses and speechlanguage therapists. Establishing adequate feeding abilities in the at-risk infant is an important function of the speechlanguage therapist as there is a djrect relationship between the development of the oral mechanism during feeding and the development of it's coordination for speech production. Feeding also influences the development of personal-social skills, cognitive development, perceptual and sensory development, communication development and promotes mother-child interaction (Shanks, 1983). Education of not onl y the respondents, but also of nurses in general, concerning these issues is important to ensure chat all hospitalized at-risk infants and toddlers receive the best possible services to help them to develop to their full potential.

Knowledge regarding factors and conditions contributing to early communication disorders
According to Figure 3 the respondents evidenced adequate knowledge regarding factors and conditions contributing lo communication delays and disabilities, but do not appear to realize the potential negative effect of feeding problems (70'¾ responded tha1 il may sometimes he a problem) nnd low birth weight (68~ re$ponded that ii may sometime!> be a problem) on communication develupmcnl. Infants with low binh weigh! and infants with feeding problems arc at increased risk of communication delays or disabilities. Feeding problems are associated with limited motor ubility that interfere~ with the rnovemenL~ of 1he mouth necc ~ary for speech production (Copeland & Kimmel, 1989).
Consensus has been reachcJ in the literature thnt low birth weight and prematurity arc the two most important high-risk fuctor-. contributi ng to communicaLfon di~orders ( Rossetti. 1990( Rossetti. . 1996. Nur-=e!> need to be sen!.iti1ed tO the~e two imponant ri!-k focLUrs in order Lo make early referral, 10 the spcech-languuge therapisI anti target these infanll! and toddlers for participation in Early Communication lntcrven-I ion programme!..

Knowledge regarding the identification of communication delays and clisabilities ip infants and toddlers 0-24 months
According lo the results of the study the majority of lhe rcspondenLo; correctly identified option~ provided to them as symptoms of a communication di!.ordcr. indicating lhat they were able to identify early communicatilm disorder" or delnys in infants and toddlers between 0 -24 months of age.

l'erceptions and attitudes of communication interaction with hospitalized infants and toddlers 0-24 months
The respondent~' perception:-of communication interal'.· lion wiIh infanli-and w<ldler') in 1hcir care are illm,tra1cd in Figure 5. According to Figure 5 IOO'if of 1he rc:-.pondenLi; alway:,, tall.. to the infant!. while bathing them. 97'7r Cl-tabli~h cye-contal'I during feeding. und 90'fr l!mile in reaction to infanL,;' vocalizations. The re,pondents appe:ir lo fully understand the imponance of communication intcr..ictioo with the ho!ipitalized rnfanl and tu<ldler since they implement differentstratcgie:-. tn achieve th.is goal. From the above it can he cuncludeu lhat. in this regard, the maj1Jri1y of rc~ponc.lent:-· ntlitudes complemented their perceptions. Rc~ults presented in Figure 5 how that. although Ihe rei.pondents did have upponunities for !iocial interaction with infants and Loddlen, in their care. they did nut always take full advantage of them as only 50~ always named objects and 54'½-imitated the infant!;' vocalizationi. during contact. II i-. also apparent that the respondents did 1101 always have the time to re!.pond to infants· and toddlers' communicutinn attempt:-.. Heavy patic:nt loads at times were cited as a reason preventing nurses from providing social ),timulation. Although re:-earch ( Miller & Holditch-Davis, 1992) has found no relation between staff-patient ratio!. and

Attitudes towards and perceptions of a teamapproach to Early Communication Intervention
According to Fig ure 6 the respondents are well versed in the importance of a team approach to Early Co mmunicatio n Intervention. I 00% of the res pondents agreed that consultation with other professio nals is essential in the treatment of high-risk infants, that the e xchange of knowledge should take place regularly and that mutual exchange of knowledge and skills between nurses and speech-la nguage therapists is the core of Early Communication Interventio n. This finding could be attributed to training that the respo ndents received before qualifying and the approach of their cun-e nt wo rk settings. The formulation of the questio ns may, however, also have been interpreted as a leading questi on. The small percentage of respondents who had insufficient knowledge of the team-approach could limit the impleme ntatio n thereof. This lack could be addressed by means if in-service educatio n programmes. It is s upported by the faci !hat a larger percentage of respondents had expressed the desire to obtain more informatio n (See Table 2). Imprecise definiti ons of roles and responsibilities and the lack of involvement of key pe rsonnel have bee n ide ntified as being ban-iers in the terun approach. It is impor1ant that each member in a team maintains the necessary balance for effecti ve interaction to occur ( Briggs, 1993).

Requests for additional information on Early Communication Intervention
Finally the respo nde nts we re requested to indicate whethe r they felt comfortable with their knowledge regarding communication with infants a nd whethe r they would like additio nal information on the subject. Table 2 indicates that, even though the maj ority (57%) of the responde nts felt comfortable with their kno wledge, 92% of the responde nts expressed the desire to o btain more information. This is see n to be indicative of the responde nts' positive attitude and receptivity to new information and their interest in the to pic. This positive attitude embodies the spirit of tea m work which is essential for effective service de li very ( Briggs, I 993, Rossetti, 1996).

CONCLUSIONS AND IMPLICATIONS FOR NURSING PRACTICE
Although this study was conducted on a small sample in a single geographical area, the dearth of international literature regarding the topic ,md nature of results make the findings of interest to all mrrses involved in the care of at-risk infants and toddlers .
Thjs study showed that the responde nts perceived the role of the nurse in Early Communicatio n Intervention to be important and that the majority had sufticient knowledge to refer at-risk infants and toddlers for Early Communication Inte rvention. However, the results also s uggest that the respondents need a stronge r knowledge base, require education and training in not only providing communicatio n stimulatio n to infants and toddlers in their care, but also in utilizing oppo rtunities for social inte raction and acting as role models for pare nts within the team framework. This may be achieved by continued professional contact, closer networking between the two professions and in-service training. Speech-lang uage therapists need to co-o perate with nurses and vice versa in early service delive ry by adhe ring to and maintaining all nursing and speech-language therapy protocols, which are mutually suppottive, consulting with and demonstrating to each other their relevant services. By sharing desctiptions of the roles of the nurse and speech-language therapist in early communication intervention, these key members could work towards common goals and the delivery of effective and accountable services.
By fulfilling their role in Early Communication Intervention, nurses could provide optimal services to the benefit of infants and toddlers who are at-risk for communication disorders, thereby preventing later secondary disabilities. Professionals engaged in treating and monitoring developmental progress are privileged to contribute to the total child, who will ultimately live and learn to their maximum (Shanks, 1983). The challenges of providing effecti ve and accountable Early Communication Intervention services are great. A commitment to meeting those challenges can result in meaningful professional and personal rewards for both the nurse and the speech-language therapist.