Ab Initio International Spring 2009
Feature Article

The NBO as a Nursing Intervention
The Newborn Behavioral Observations System as a Nursing Intervention to Enhance Engagement in First-Time Mothers: Feasibility and Desirability

Leslie W. Sanders, RN, Ellen B. Buckner, DSN, RN


Figure 1 Newborn exhibiting reciprocity through mimicry of facial expressions.
Engagement is the social process of maternal transition that enables growth and transformation and is linked to attachment and bonding. The feasibility and desirability of the Newborn Behavioral Observations (NBO) system as a nursing intervention to enhance engagement in first-time mothers were examined. The NBO is an exploration of the newborn conducted with parents to increase their understanding of their infant's behavioral cues and how to respond. Perceptions of the NBO were obtained from mothers who participated in NBO sessions in the postpartum period and unit nurses who had been given information on the NBO. Mothers (n=10) rated the NBO high for increasing their knowledge of what their infants can do (m=3.7/4.0, SD=.48), and how to interact with them (m=3.8/4.0, SD=.63). Two of the activities of engagement, experiencing the infant and active participation in care, emerged as themes from the mothers' qualitative responses. Nurses (n=20) believed the NBO would be an effective intervention. Participants believed the NBO to be an effective nursing intervention for enhancing maternal engagement in the early postpartum period.

The birth of a first child is a time of enormous change, instability, and uncertainty in a woman's life. Indeed it is a time of developmental transition when the mother's task is the attainment of the maternal role (Beeghly, Flannery, Nugent, Barrett, & Tronick, 1995; Boland, 2002; Brazelton & Nugent, 1995; Nelson, 2003; Nugent & Blanchard, 2005). Successful completion of this task is crucial to the well being of the mother, and ultimately the infant as ineffective maternal role transition, poor attachment and unsuccessful bonding have been linked to abandonment, developmental delays, and failure to thrive syndrome (Leitch, 1999; Lowdermilk & Perry, 2000; Nelson, 2003; Kennell & Klauss, 1998; Rubin, 1967; Schenk, Kelley, & Schenk, 2005). Transition to the maternal role requires that mothers be engaged with their infants so that bonding and attachment can occur (Brazelton & Nugent, 1995; Nelson, 2003; Goulet Bell, Tribble, Paul, & Lang, 1998 Kennell & Klauss, 1998; Schenk, Kelley, & Schenk, 2005).

Studies have shown that by orienting new mothers to the unique behavioral characteristics of their infants, the central activities of engagement can be fostered and barriers to maternal role transition can be overcome (Brazelton Institute, n.d.; Golas & Parks, 1986 Lydic & Nugent, 1982). It has been suggested that the postpartum period is a "teaching moment par excellence" for new families, a time when families are primed to be engaged with their infants, and a time when bonding is heightened (Blanchard, Kerzner, & Nugent, 2005; Kennell & Klauss, 1998; Nugent & Blanchard, 2005). Therefore nurses, as the primary caregivers in the immediate postpartum period, are in a perfect position to initiate interventions to enhance the activities of engagement that are so important to maternal role transition. The purpose of this study was to assess the feasibility and desirability of the NBO system as a nursing intervention to foster maternal engagement during the first days of life in the inpatient setting.

Review of the Literature

In a meta-synthesis of qualitative studies on the transition to motherhood, Nelson identified engagement as the basic social process of maternal role transition (Nelson, 2003). The central activities of engagement identified were, experiencing the presence of the infant by the mother, the mother's active participation in care, and maternal commitment. Bonding is the mother's coming to know, love, and accept the new infant, and is defined as an enduring relationship between parent and child that is unique, positive, and specific to the particular child and occurs through the process of attachment (Bowlby, 1969; Harrison, Sherrod, Dunn, & Oliver, 1991; Hewitt, Bihum, & Goldsmith, n.d.; Kennell & Klauss, 1998). Goulet, et al., identified three attributes as central to attachment: proximity, reciprocity (Figure 1), and maternal commitment (Goulet, et. al., 1998). Upon comparison, engagement emerges as a process through which attachment and bonding are fostered. Experiencing the infant requires the proximity of attachment, active participation occurs through the reciprocal behaviors of the mother and infant, and maternal commitment is central to both engagement and attachment. Therefore engagement is not only the basic social process of maternal role transition, but is also linked inexorably to the important processes of attachment and bonding (Figure 2).

One of the barriers to the transition to motherhood has been shown to be infant temperament. Infants who are perceived as ill-tempered and hard to care for, or who exhibit those characteristics due to a lack of effective maternal responsiveness to their behavioral cues can be susceptible to negative parent-child interactions and impairment of maternal bonding (Barnard, n.d.; Hewitt, et. al., n.d.; Pokorni, 1996; Porter & Hsu, 2003; Widmayer & Field, 1981). This can be overcome by helping mothers better understand the challenges which their infants' temperaments may present, and discover the stimuli and comfort measures that elicit their infants' best responses (Brazelton & Nugent, 1995). Thus, the mother's understanding of the infant is increased and any feelings of guilt that the infant's "bad" behaviors are due to poor caregiving are allayed (Gibes, 1981, Golas & Parks, 1986).

Over 30 years ago Brazelton recognized that newborns are not passive participants in their care, but instead possess a rich array of abilities to express needs and elicit parental responses even in the immediate postpartum period (Brazelton & Nugent, 1995). Infant behaviors express attempts, failures, and successes at self regulation, stress, and social readiness (Brazelton & Nugent, 1995; Blanchard, Kerzner, & Nugent, 2005). The Neonatal Behavioral Assessment Scale (NBAS), introduced by Brazelton in 1973, (Brazelton & Nugent, 1995) has proven to be a means by which to understand the complexities of the newborn in a variety of populations and has been shown to be an effective neurobehavioral assessment tool and aid in the early prediction of later child temperament and developmental problems (Als, Tronick, Lester, & Brazelton, 1979; Brazelton & Nugent, 1995; Gibes, 1981; Ohgi, Takahashi, Nugent, Arisawa, & Akiyama, 2003). Additionally, since its inception, the NBAS has been increasingly recognized as an effective clinical tool for nursing assessment, planning and intervention (Brazelton Institute, n.d.; Buckner, 1983; Gibes, 1981; Harrison, et. al., 1991; Kennell & Klauss, 1998; Lydic & Nugent, 1982; Nugent, 1981; Widmayer & Field, 1981).

Based on over 25 years of experience with the NBAS, Nugent, Keefer, O'Brien, Johnson and Blanchard (in prep) developed the NBO as a more flexible clinical intervention tool to promote positive parent-infant relationships that could be more easily incorporated into routine care (Brazelton Institute, n.d.; Nugent, 2006). The NBO is designed to orient parents to the characteristics and competencies of their newborns by assessing, with them, their infant's responses to a variety of neurobehavioral assessment items (Blanchard, Kerzner, & Nugent, 2005; Northern Lights, 2003). Throughout the session the clinician encourages parents to explore the knowledge they already posses about their infants and make predictions and observations (Northern Lights, 2003). This shared exploration of the infants' responses guides the examiner in providing anticipatory guidance for caregiving. In initial trials, the NBO was rated high by pediatric professionals (n=222), and parents (n=31) as good or excellent in helping parents learn about their infants and fostering interest, however more research is needed (Nugent & Blanchard, 2005; Blanchard, Kerzner, & Nugent, 2005).


The investigator completed training in the administration and use of the NBO at The Brazelton Institute and obtained Institutional Review Board (IRB) approval. Participant confidentiality was protected throughout the study by eliminating identifying data. A convenience sample of first-time mothers was recruited from the mother/baby unit at a large university hospital. The participants were limited to first-time mothers, over age 19, who were rooming-in with their healthy term infants. Informed consent was obtained, demographic data were collected, and an NBO session was conducted by the investigator with the mother and infant.

After the NBO session the investigator conducted interviews with each mother to elicit their perceptions of the intervention. The interview questions measured the mother's opinions of the effectiveness of the NBO to enhance activities that would increase engagement. The interview consisted of open-ended questions and closed-ended questions that mothers scored on a Likert-type scale. Higher ratings indicated a more positive opinion of the intervention. The interview questions were reviewed for content validity by three experts. The questionnaire had a Cronbach alpha of 0.96 when the questions concerning barriers to participation and level of enjoyment were excluded from analysis.

After the NBO session and interview mothers completed a Newborn Behavioral Observations (NBO) Parent Questionnaire developed by the Brazelton Institute. The purpose of the questionnaire was to further asses the usefulness of the NBO in teaching parents and enhancing engagement. The NBO questionnaire is a Likert-type scale that rates items on a 4 point scale.

After the intervention the investigator rated the mothers' participation during the intervention The Maternal Participation Scoring tool was used in the study to rate maternal behaviors during the NBO sessions and to assess its usefulness for triangulating data. The Maternal Participation Scoring Tool is a 3 point Likert-type scale. A higher rating reflected greater participation in the demonstration. Content validity was reviewed by three experts. Interrater reliability was established between the investigator and an experienced clinician at 100%. The Maternal Participation tool had a Cronbach alpha of 0.73 when the item regarding whether mothers related the baby's behavior to previous knowledge was excluded from analysis.

After completion of the mothers' segment of the study, the investigator gave presentations to the mother/baby unit nurses at two staff meetings. The presentations included the conceptual and theoretical basis of the study, and results of the mothers' interviews, questionnaires, and participation scoring. The nurses then completed questionnaires on the feasibility and desirability of using the NBO on their unit.


Sample. Sample characteristics of the mothers (n=10) included six African Americans, two Caucasians, one Asian, and one Indian participant. Four were single, two were living with a partner, and four were married. Participants ranged in age from 19 to 27. The most frequent income range was $15000 to $18000 (n=3), with one under $15000, two from $18001 to $20000, and two in the $25001 to $30000 range. Two did not indicate an income range. Six participants reported greater than a high school education. Four of the participants had attended prenatal classes. No demographic data were collected from the sample of mother/baby unit nurses (n=20).

Feasibility. Feasibility issues of particular interest were cost, barriers, and length of time to administer. The costs of one day training for professionals break down as follows: $200 for professionals in training, residents, and fellows, $400 for physicians, $300 for nurses and allied professionals. On-site group training is also available for 25-30 participants at a cost of $10,000.

Sessions were occasionally interrupted or delayed due to other activities but there were no significant barriers to implementing the NBO as an intervention in the postpartum period identified by the investigator or the mothers who participated. The NBO sessions lasted between 20 and 30 minutes with an average length of 25 minutes.

When nurses were asked if they could include an NBO session in their routine patient care, n=7 said yes, n=6 said no, and n=7 were unsure. Nurses were split on who should perform the NBO sessions between the choices of the mother's nurse (n=5), the infant's nurse (n=8) and a specialist (n=11) (some chose more than 1 option).

Desirability. The mothers' responses to the quantitative interview questions are presented in Table 1. Minimum and maximum scores, means, and standard deviations are reported for each question. Items were rated on a 4 point scale from 1 (nothing) to 4 (a lot).

Table 1 Interview Questionnaire Results

N = 10 Minimum Maximum Mean SD
Did you enjoy the NBO session? 3.00 4.00 3.40 0.52
Did it encourage you to discover more about your baby? 3.00 4.00 3.60 0.52
Did it increase your knowledge of your baby's behavior? 1.00 4.00 3.20 1.03
Did it increase your understanding of your baby's behavior? 2.00 4.00 3.10 0.74
Did it reinforce what you had already learned? 2.00 4.00 3.10 0.74
Did it help you learn how to meet your baby's needs? 2.00 4.00 3.00 0.82
The mothers' perceptions of the effectiveness of the NBO as reported on the NBO Parent Questionnaire are listed in Table 2. Minimum and maximum scores, means, and standard deviations are reported for each. Items were rated on a 4 point scale from 1 (nothing) to 4 (a lot).

Table 2 NBO Parent Questionnaire Results

N = 10 Minimum Maximum Mean SD
How much did you learn about ...what your baby can do? 3.00 4.00 3.70 .48
...how your baby can communicate? 2.00 4.00 3.50 .85
...how you can respond? 3.00 4.00 3.50 .71
how you can help when your baby is crying? 3.00 4.00 3.60 .52
...how to interact with your baby? 2.00 4.00 3.80 .63
...how baby can regulate sleep? 3.00 4.00 3.50 .53
Overall how much would you say the NBO helped you... feel closer to your baby? 3.00 4.00 3.10 .57
...feel more confident as a parent? 3.00 4.00 3.60 .52
...get to know more about your baby? 2.00 4.00 3.50 .71
...communicate with or relate to the person conducting the NBO? 3.00 4.00 3.75 .46
Overall how would you rate the NBO as a learning experience? 3.00 4.00 3.70 .48

The mothers' participation in the intervention was rated to determine if any correlation existed between the observed level of participation and the mothers' reported effectiveness of the NBO in increasing engagement activities. Eight maternal behaviors that displayed maternal interest in the activities were rated on a 3 point scale from 1 (nothing) to 3 (a lot). The Pearson correlation coefficient between the mean scores of the closed-ended interview questions and the Maternal Participation tool was statistically significant (r = 0.66, P<0.05).

Qualitative data elicited from the mothers were analyzed using constant comparative analysis to identify themes. Mothers were asked what they liked about the intervention, what they learned about their infants, and how it could help them in caregiving. Analysis of the qualitative data revealed three main themes. Mothers reported that the intervention was useful, that it encouraged them to experience their infant, and that it taught them ways to actively participate in caregiving. Table 3 lists participant responses under each theme.

Table 3 Themes identified as benefits of the NBO by mothers.

Usefulness of the NBO Experiencing the Infant Active Participation in Care
"I enjoyed it...it would be good for other moms." "Watching [the baby]" "Introduced to some new techniques for baby care."
"The session was useful." "Learning about [the baby]", "I will pay attention to what [the baby] is trying to tell me."
"Everything was useful." "Interacting with [the baby]" "Soothing techniques."
"The NBO is good and useful." "Techniques for monitoring different behavioral items" "Paying attention to cues and how noise affects her."
"The person conducting...gave useful suggestions." "Learning about [the baby's] temperament." "Responses to noisy environment."
"I liked it a lot." "Learning about [the baby's] strength." "Tummy time."
"I learned a lot." "Learning about [the baby's] abilities." "Feeding before [the baby] cries."

Nurses (n=20) reported that there was a need among their patient population for interventions that help parents learn about there infants, with n = 3 indicating a need in some or most patients and the remainder (n = 17) indicating a need in all patients. Most (n = 18) recognized a need for interventions that enhance engagement in all patients, the remainder saw a need in some or most. The nurses thought that the NBO would help parents learn about their infants (n = 20), and enhance maternal engagement (n = 20). When asked if they thought their patient population would benefit from the NBO, 75% of nurses (n = 15) said all or most would, the others were either unsure (n = 1) or believed some patients would (n = 3).

Those nurses who gave qualitative data indicated that they thought the NBO would benefit their patients by increasing their knowledge and understanding of their infants, decreasing fear, learning about development, and increasing bonding and confidence. Some respondents indicated specific populations that would benefit such as, first-time mothers, high parity mothers, young mothers, or those with low socioeconomic status.


Nurses are in a prime position to support and implement interventions that enhance engagement in first-time mothers in the postpartum period. Interventions such as the NBO that help mothers learn to recognize, understand, and respond to the behavioral cues of their infants could be used by unit nurses or nurse specialists with all mothers or those identified as being at risk for ineffective maternal role transition. This study suggests that there is a great need among mothers for measures that increase their understanding of their infants and that the NBO could be an effective nursing intervention in enhancing engagement, encouraging maternal role transition, and promoting attachment and bonding.

Nurses who participated in this study overwhelmingly identified a need among their patient populations for interventions that enhance engagement and help mothers learn about their infants and unanimously believed the NBO would be effective in doing so. There were few barriers identified by participants or the investigator. Although, because some of the nurses in this study thought that their current patient load may prohibit their routine use of the NBO, it may be more cost and time efficient to have one or more nurses specializing in patient education and newborn assessment conduct NBO sessions with all families or those identified as high risk.

Mothers rated the NBO high for its efficacy in increasing their knowledge of their infants and how to respond to and interact with them. Participants also rated the NBO high as an overall learning experience. Qualitative data revealed strong support for the usefulness of the NBO and its ability to enhance engagement activities. A significant finding was that two of the components of engagement, experiencing the infant and active participation in care, emerged as benefits of the intervention.

The results of this study suggest that the NBO could be a desirable and efficacious intervention to enhance engagement in first-time mothers. The primary limitations to the application of the results of this study to the larger population were the use of a small convenience sample and screening criteria that limited the inclusion of data from a larger, more diverse population. Future studies should target a larger sample of first-time mothers. Research should also target a large heterogeneous sample to identify situations in which the NBO would be most beneficial, and then focus studies on specific groups of mothers identified as being at increased risk for ineffective role transition such as adolescents, mothers of premature infants, single mothers, those who lack support, and those with limited resources. Additionally, to add to the body of knowledge on culturally competent care, studies should be conducted to determine if the NBO could successfully be used with mothers from various cultures.


The author would like to express a special word of thanks to Dr. Ellen Buckner, Dr. Kevin Nugent, Dr. Lynda Harrison, Ashley Wood, Dr. Jill Ross, Jennifer Kelley, the unit nurses and participants for their support and encouragement. The investigator also acknowledges the UAB School of Nursing Honors Fund for partial reimbursement of expenses.


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Reprinted from Pediatric Nursing Journal, 2006, Volume 32, Number 5, pp. 455-459.
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