Parents' Perspectives of Closeness and Separation With Their Preterm Infants in the NICU

Parental presence, participation, and engagement in paediatric hospital care: A conceptual delineation

AIM

To delineate between the concepts of parental presence, participation, and engagement in paediatric hospital care.

DESIGN

The concepts' uses in the literature were analysed to determine attributes, influences, and relationships.

METHODS

Delineations of each concept are established and conceptual definitions are proposed following Morses' methods.

DATA SOURCES

MEDLINE (PubMed); CINAHL, PsycINFO, Sociology Source Ultimate (EBSCOhost); Embase, Scopus (Elsevier); Google Scholar. Search dates October 2021, February 2023.

RESULTS

Multinational publications dated 1991-2023 revealed these concepts represent a range of parental behaviours, beliefs, and actions, which are not always perceptible to nurses, but which are important in family-integrated care delivery. Parental presence is the state of a parent being physically and/or emotionally with their child. Parental participation reflects parents' performing caregiving activities with or without nurses. Parental engagement is a parents' state of emotional involvement in their child's health and the ways they act on their child's behalf.

CONCLUSION

These concepts' manifestations are important to parental role attainment but may be inadequately understood and considered by healthcare providers.

IMPLICATIONS

Nurses have influence over parents' parental presence, participation, and engagement in their child's care but need support from healthcare institutions to ensure equitable family-integrated care delivery.

IMPACT

Problem: Lack of clear definition among these concepts results in incomplete and at times inequitable family-integrated care delivery.

FINDINGS

Parental presence is an antecedent to parental participation, and parental presence and participation are elements of parental engagement. The concepts interact to influence one another.

IMPACT

Hospitalized children, their families, nurses, and researchers will benefit through a better understanding of the concepts' attributes, interactions, and implications for enhanced family-integrated care delivery.

Parents' Shared Experiences of Separation From Their Newborns After Birth in Denmark

OBJECTIVE

To explore parents' shared experiences of separation from their newborns after birth in Denmark.

DESIGN

Phenomenological hermeneutic design.

SETTING

A NICU in the Capital Region of Denmark.

PARTICIPANTS

Four sets of parents (N = 8) with prematurely born neonates who were admitted to the NICU.

METHODS

We used dyadic interviews for data collection. We applied a phenomenological hermeneutic approach inspired by Ricoeur's theory of interpretation to analyze the data.

RESULTS

Two overarching themes emerged that reflected two distinct temporal phases of separation. Initial separation caused an experience of becoming parents at different paces. Separation based on care needs (i.e., the NICU vs. maternity unit) left parents at the juncture between separation and closeness.

CONCLUSION

Separation from their newborns complicated parents' transitions into parenthood. Their sense of unity was undermined when different units assumed responsibility for the mother and newborn. This challenged family-centered care. Our findings indicate the need to minimize separation through initiatives such as zero separation and couplet care.

Parents' and neonatal healthcare professionals' views on barriers and facilitators to parental presence in the neonatal unit: a qualitative study

BACKGROUND

Parent and infant separation in the neonatal unit is associated with adverse health outcomes. Family-integrated care has several advantages and the potential to reduce these adverse outcomes but requires parental presence. This study aimed to explore the views of parents and neonatal healthcare professionals (nHCPs) on barriers and facilitators to parental presence in a Swiss neonatal unit and to identify possible differences between nHCPs and parents, and between mothers and fathers.

METHODS

Data were collected through semi-structured interviews with parents and focus group discussions with nHCPs. Inductive content analysis was used to identify barriers and facilitators to parental presence in the neonatal unit.

RESULTS

Twenty parents (10 mothers and 10 fathers) and 21 nHCPs (10 nurses and 11 physicians) participated in the study. Parents and nHCPs experienced barriers and facilitators related to: (1) Structural factors of the institution, such as infrastructure or travel and distance to the neonatal unit. (2) Organization and time management of parental presence, daily activities, and work. (3) Resources, which include factors related to the legal situation, support services, family, and friends. (4) Physical and psychological aspects, such as pain, which mainly affected mothers, and aspects of emotional distress, which affected both parents. Self-care was an important physical and psychological facilitator. (5) Parent-professional interaction. Parental presence was influenced by communication, relationship, and interaction in infant care; and (6) Cultural aspects and language. Some perspectives differed between mothers and fathers, while the overall views of parents and nHCPs provided complementary rather than conflicting insights. Using visit plans to support the organization, educating nHCPs in knowledge skills and available resources to improve encouragement and information to parents, strengthening parent self-care, and improving nHCPs' attitudes towards parental presence were seen as possible improvements.

CONCLUSIONS

Multifactorial barriers and facilitators determine parental presence and experience in the neonatal unit. Parents and nHCPs made specific recommendations to improve parental presence.

The Impact of Physical and Environment Factors on Parental Presence for Oral Feeding in New Zealand Neonatal Intensive Care Units

AIM

To identify physical environmental factors influencing family involvement in feeding in New Zealand neonatal units.

BACKGROUND

Infant oral feeding development is critical for both short-term feeding skills and longer term neurodevelopmental outcomes. The neonatal environment is well-known as challenging for neuroprotection due to negative sensory exposure. The impact of environmental factors on oral feeding in New Zealand (NZ) neonatal units is currently unexplored, and knowledge of this could allow for evidence-based unit design.

METHODS

Focused ethnography at five neonatal units, a national survey of NZ neonatal professionals (n = 102), and five focus groups were carried out. Current oral feeding practice, and beliefs, experiences, and opinions of unit staff and family about these practices were explored. Data were analyzed using qualitative content analysis.

RESULTS

Units were providing the best experience to families that they could with the resources they had available. Lack of physical space, lack of privacy, limited on-site accommodation for families, and lack of coordination between maternity and neonatal services were identified as impacting on family's comfort and sense of homeliness on the unit. Unit staff used furniture, screens, and external accommodation providers to support families where they could.

CONCLUSIONS

The physical design of neonatal units in New Zealand provides barriers to family's spending time privately developing oral feeding. Solutions are proposed to increase the size of bedspaces, provide single-family rooms, create greater on-site family accommodation options, combine maternity and neonatal healthcare, and improve family comfort and therefore connection with their infant.

A Concept Analysis of Paternal Bonding With Prematurely Born Infants

BACKGROUND

Maternal bonding in infancy has long been the focus of research and practice. Despite emerging evidence highlighting the importance of paternal bonding, little attention has been focused on fathers. Simultaneously, there is little clarity regarding possible differences between bonding and attachment.

PURPOSE

This article aims to clarify the concept of paternal bonding with infants born prematurely.

METHODS/SEARCH STRATEGY

Using Walker and Avant's approach to concept analysis, we selected databases and searched them for relevant studies published between 2012 and 2022. We identified 28 articles that (1) defined bonding specific to fathers of infants born prematurely, (2) were peer-reviewed, and (3) were in English. From the articles, we extracted and analyzed data specific to concept definitions, antecedents, and consequences.

RESULTS

Regarding paternal bonding with infants born prematurely, our analyses of the 28 studies yielded a conceptual definition of this topic that extends beyond the commonly used definition emphasizing emotional connection. The newly formulated definition covers the cognitive, behavioral, and dynamic, as well as emotional, attributes of bonding. We identify and discuss antecedents and consequences of bonding.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Our findings led to a consistent conceptual definition of the bonding phenomenon in question. The definition should serve as a conceptual basis for future guidelines governing clinical practice and research. Through our findings, nurses can better understand and promote paternal bonding with infants born prematurely. Finally, our findings can improve researchers' exploration of this topic.

Measurement invariance analysis of the Postpartum Specific Anxiety Scale - Research Short Form in mothers of premature and term infants

OBJECTIVE

Mothers of premature infants are more likely to develop anxiety during the first postpartum year than mothers of term infants. However, commonly used measures of anxiety were developed for general adult populations and may produce spurious, over-inflated scores when used in a postpartum context. Although perinatal-specific tools such as the Postpartum Specific Anxiety Scale [PSAS] offer a promising alternative form of measurement, it is not clear whether the measure performs similarly in mothers of premature infants as it does in mothers of term infants. The objective of the current study was to identify whether items on the Postpartum Specific Anxiety Scale - Research Short Form (PSAS-RSF) are being interpreted in the same manner in mothers of term infants and mothers of premature infants. Mothers (N = 320) participated in an international on-line survey between February 2022 and March 2023 (n = 160 mothers of premature infants, n = 160 mothers of term infants) where they completed the PSAS-RSF. Data were analysed using a measurement invariance analysis to assess whether constructs of the PSAS-RSF are performing in a similar manner across the two groups.

RESULTS

Whilst the PSAS-RSF achieved configural invariance and so retains its four-factor structure, metric invariance was not reached and so items are being interpreted differently in mothers of premature infants. Items concerning infant-separation, finance, and anxieties surrounding infant health are potentially problematic. Future research must now modify the PSAS-RSF for specific use in mothers of premature infants, to ensure measurement of anxiety in this population is valid.

'Not a goal, but a given': Neonatal care participation through parents' perspective, a cross-sectional study

AIM

To explore parents' perspectives regarding participation in neonatal care, with focus on the family integrated care (FICare) model utilised as a tool to enhance parent-infant closeness. Additionally, we describe experiences in different architectural settings.

METHODS

An online survey, categorised by four FICare pillars, was distributed through social media to parents of newborns hospitalised to Dutch neonatal wards between 2015 and 2020. Quantitative findings were summarised using descriptive statistics, while open-ended responses were thematically analysed.

RESULTS

Among the 344 respondents (98% mothers), most reported feeling involved in care (315/340). However, 79% also felt separated from their infant (265/337). Irrespective of architectural settings, parents reported incomplete implementation of FICare pillars: 14% was invited to educational sessions (parent education), 51% discussed family-specific care plans (staff education), 21% was facilitated in connecting with veteran parents (psychosocial support) and 22% received couplet-care (environment). Although 65% of parents were invited to attend clinical rounds, 32% actively participated in decision making. Thematic analysis revealed fundamentals for feeling welcome on the ward, peer-to-peer support, psychosocial support and participation in clinical rounds.

CONCLUSION

Overall, parents expressed satisfaction with participation in neonatal care. However, structural implementation of FICare lacks. Regardless of architecture, expanding parent participation beyond presence requires attention.

Fresh Parent's Own Milk for Preterm Infants: Barriers and Future Opportunities

While direct at-the-breast feeding is biologically optimal, Neonatal Intensive Care Unit (NICU) admission due to infant immaturity or illness often necessitates the expression and storage of parent's milk. The provision of freshly expressed (never stored) parent's own milk to preterm infants is not widely prioritized, and this article provides an exploration of NICU practices and their implications for feeding premature or ill infants with parent's own milk. In this article, we discuss the potential biological benefits of fresh parent's own milk, highlighting its dynamic components and the changes incurred during storage. Research suggests that fresh milk may offer health advantages over stored milk. The authors advocate for further research, emphasizing the need for standardized definitions. Research is needed on the biological impact of fresh milk, both short- and long-term, as well as defining and understanding healthcare economics when using fresh milk.

What matters to families about the healthcare of preterm or low birth weight infants: A qualitative evidence synthesis

OBJECTIVE

We examined what matters to families about the healthcare provided to preterm or LBW infants in hospital and the community, to ensure that care meets the needs of infants and parents.

METHODS

We searched databases to identify eligible studies examining the views and expectations of families. Study quality was assessed using the CASP checklist for qualitative studies. The GRADE-CERQual approach was used to assess confidence in review findings. Studies were sampled and data analysed using thematic synthesis.

RESULTS

222 studies (227 papers) were eligible for inclusion. 54 studies (57 papers) were sampled based on data richness, methodological quality, and representation across settings. Eight analytical themes were identified. Confidence in results was moderate to high. What mattered was a positive outcome for the child; active involvement in care; being supported to cope at home after discharge; emotional support; the healthcare environment; information needs met; logistical support available; and positive relationships with staff.

CONCLUSION

Although parents and family members reported a variety of experiences in the care of their infant, we found high consistency in what matters to families.

PRACTICE IMPLICATIONS

This review identifies approaches to improve experiences of parents which are consistent with the Family Centred Care model of healthcare.

Improving NICU staff decision-making with parents in medical rounds: a pilot study of reflective group dialogue intervention

Introduction

The communication skills of healthcare professionals play a crucial role in successful shared decision-making with parents in neonatal intensive care. Improving communication skills can be achieved through practice and reflection on personal experiences after authentic interaction events with parents. The process of reflection typically involves three phases: description, reflection, and critical reflection. In this study, our aim was to explore the acceptability of the Reflective Group Dialogue intervention and its effectiveness in supporting the reflective process.

Methods

This qualitative pilot study was conducted in the neonatal intensive care unit at Uppsala University Children's Hospital, Sweden. The sample consisted of nine medical rounds with seven families, five neonatologists, seven registered nurses, and five assistant nurses. Purposive sampling was used to collect the data. The intervention comprised four elements: (1) before the intervention, a recorded presentation on shared decision-making was given to the entire unit staff, (2) an observation of a normal medical round discussion with parents, (3) an interview with parents about their experience after the same round, and (4) a reflective discussion with the participating health care professionals after the round. The parent interviews and reflective discussions were audio-recorded and transcribed verbatim. They were analyzed using thematic analysis as a theoretical strategy.

Results

Both parents and staff widely accepted the intervention and found it beneficial. We identified four discussions that remained in the descriptive phase of the reflection process, four that reached the reflective phase, and one that reached the critical reflection phase. The descriptive discussions were characterized by using a single perspective to reflect, often based on personal opinions. The reflective discussions included analyzing interaction sequences from both staff and parent perspectives and were primarily based on actual observations of communication during medical rounds. The critical discussion led to a new awareness of current practices concerning parental involvement in decision-making. These discussions also utilized "what-if" thinking to evaluate potential new practices and their pros and cons.

Conclusions

The intervention seems promising as it was perceived as beneficial by the recipients and facilitated reflection in most cases. However, to enhance the feasibility of the intervention, some improvements are discussed.

Parental representations after preterm birth: a narrative review

Preterm birth accounts for nearly 15 million births annually worldwide and constitutes a considerable risk factor for atypical development. This birth context is a source of stress for the parents and often leads to an early separation between their child and them. Research on the influence of the birth status on the infant's attachment style has shown no systematic link between preterm birth and the development of insecure attachment in children born preterm. This has opened up research perspectives in understanding the role of environmental factors. A literature review was conducted to present an overview of the current findings on parental representations (PR), particularly maternal ones, and their role in the context of preterm birth. PR quality appears to be associated with specific dyadic interaction patterns, thus exposing vulnerability factors. Studies exploring PR have pointed out the importance of considering parental mental elaboration mechanisms and contextual moderators in supporting socio-emotional development among children born preterm. We discussed the challenges of investigating PR in the context of preterm birth for future studies and emphasized the need for research studies to be conducted according to a developmental and non-deterministic perspective. This narrative review also aimed to highlight the importance of family centered care interventions in the context of a public policy focused on the child's "First 1,000 days" of life.

Parent experiences of a remote patient monitoring program enabling early discharge from the neonatal intensive care unit with nasogastric tube feeding

BACKGROUND

This exploratory study examined parents' experiences with "Growing at Home" (G@H), a remote patient monitoring program for stable infants discharged from the Neonatal Intensive Care Unit (NICU) with continued need for nasogastric tube feeding.

METHODS

We used classical content analysis to identify and refine emergent themes from 13 semi-structured key informant interviews.

RESULTS

The primary emergent theme was the desire to return to normalcy, which was expressed as a primary motivator for participating in G@H. Parents reported G@H assisted them in transitioning from the NICU's highly medicalized setting to establishing a new normal with incorporation of their infant into their lives and families. Parental preparation is important, as some parents experienced challenges that indicate the program may not be suitable for all families.

CONCLUSIONS

Parental experiences offer insight into benefits and challenges of early discharge from the NICU and highlight opportunities to support families beginning in the NICU and as they transition home.

Patterns of Pediatric Palliative and End-of-Life Care in Neonatal Intensive Care Patients in the Southern U.S

CONTEXT

Despite high rates of mortality among infants in the Southern U.S., little is known about the timing of pediatric palliative care (PPC), the intensity of end-of-life care, and whether there are differences among sociodemographic characteristics.

OBJECTIVES

To describe PPC patterns and treatment intensity during the last 48 hours of life among neonatal intensive care unit (NICU) patients in the Southern U.S. who received specialized PPC.

METHODS

Medical record abstraction of infant decedents who received PPC consultation in two NICUs (in Alabama and Mississippi) from 2009 to 2017 (n = 195) including clinical characteristics, palliative and end-of-life care characteristics, patterns of PPC, and intensive medical treatments in the last 48 hours of life.

RESULTS

The sample was racially (48.2% Black) and geographically (35.4% rural) diverse. Most infants died after withdrawal of life-sustaining interventions (58%) and had do not attempt resuscitation orders documented (75.9%); very few infants enrolled in hospice (6.2%). Initial PPC consult occurred a median of 13 days after admission and a median of 17 days before death. Infants with a primary diagnosis of genetic or congenital anomaly received earlier PPC consultation (P = 0.02) compared to other diagnoses. In the last 48 hours of life, NICU patients received intensive interventions including mechanical ventilation (81.5%), CPR (27.7%) and surgeries or invasive procedures (25.1%). Black infants were more likely to receive CPR compared to White infants (P = 0.04).

CONCLUSION

Overall, PPC consultation occurred late in NICU hospitalizations, infants received high-intensity medical interventions in the last 48 hours of life, and there are disparities in intensity of treatment interventions at end of life. Further research is needed to explore if these patterns of care reflect parent preferences and goal concordance.

Virtual Care Across the Neonatal Intensive Care Continuum

The ongoing coronavirus disease 2019 (COVID-19) pandemic has highlighted the need for establishing effective parent and family engagement throughout all aspects of medicine. Though there has been some discussion in the literature regarding the transition from typical outpatient visits to telehealth visits, there has been less written about the inpatient approach to family inclusion. Here, we seek to describe our institution's experience with implementing virtual medicine across the full continuum of the neonatal intensive care unit (NICU) experience, including inpatient rounding, child life family visits, and outpatient high-risk developmental follow-up after discharge.

NICU Parents of Black Preterm Infants: Application of the Kenner Transition Model

BACKGROUND

Black infants in the United States have the highest incidence of both infant mortality (IM) and preterm birth among all racial/ethnic groups. The IM disparity for Black preterm infants often occurs after neonatal intensive care unit (NICU) discharge, when parents become the primary caregivers. The revised Kenner Transition Model (KTM) is situation specific and comprised 5 interrelated domains of parental need after NICU discharge that have not been previously applied to the transition from NICU to home of Black infants.

PURPOSE

This study's purpose was to explore the conceptual fit of parental readiness to care for their Black preterm infants after NICU discharge with the revised KTM.

METHODS

A qualitative descriptive research approach was used for this single-site study of NICU parents of Black preterm infants. Qualitative analysis of 10 parents' perceptions before NICU discharge was via semantic content analysis; data were organized into categories aligned with the KTM. The Transition Questionnaire (TQ), an adjunct to the KTM, provided self- report quantitative data.

RESULTS

All parents endorsed the "Information Needs," "Stress and Coping," and "Professional Support" domains of the KTM. Parent TQ responses indicated perceptions of moderate to high levels of home transition readiness after NICU discharge.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The domains of the revised KTM were affirmed by parents of Black preterm infants in this study via coded interview and TQ responses. Additional study exploring the clinical assessment of transition readiness with theoretical grounding in diverse NICU families is warranted.

VIDEO ABSTRACT AVAILABLE AT

https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx .

Parental experiences in neonatal intensive care unit in Ethiopia: a phenomenological study

INTRODUCTION

Neonatal intensive care unit is important to save the lives of a sick neonate; however, parents are challenged by several stressful conditions during their stay. Therefore, this study aimed to explore the lived experiences of parents in neonatal intensive care units in Ethiopia.

METHODS

We used a phenomenological study design. The data were collected using an in-depth interview method from purposively selected parents. In addition, we followed a thematic analysis approach and used Open Code Software Version 4.02 to process the data.

RESULTS

In this study, 18 parents were interviewed. The researchers have identified six themes. Parents complained of psychological problems like anxiety, stress, worries, hopelessness, and a state of confusion. In addition, anger, crying, sadness, frustration, dissatisfaction, regret, disappointment, feeling bad, self-blaming, nervousness, disturbance, and lack of self-control were major emotional problems raised by the parents. Parents expressed that health care providers showed indiscipline, lack of commitment, and uncooperative behaviour. Likewise, shortage of medicines, money, and limited time to visit their neonates were the other concerns of many parents. At the same time, parents were provided minimal information and limited cooperation from health care providers.

CONCLUSION

Parents whose infants admitted to the NICU were suffered from various psychological and emotional problems. Researchers recommend that health care providers should be supported parents with psycho-emotional problems, strengthen parents-healthcare workers' interaction, and scale up neonatal intensive care unit services to the primary health care centres.KEY MESSAGESParents whose infants admitted to the NICU were suffered from psychological and emotional problems.Poor NICU environment, shortage of equipment, long hospital stay, the presence of pandemic COVID-19, and lack of parental involvement in the care were identified barriers that affected parents' stay.

Understanding factors associated with emotional closeness in parents with a preterm infant in the neonatal intensive care unit

BACKGROUND

There is a dearth of knowledge regarding the specific factors associated with emotional closeness in parents with an infant in the NICU.

AIM

To determine if parental presence, involvement in infant care, holding, skin-to-skin contact (SSC), perceived family-centered care, depression symptoms, and sociodemographic characteristics are associated with the emotional closeness of parents with an infant hospitalized at the NICU.

STUDY DESIGN

This longitudinal descriptive study was conducted in two Canadian level-three NICUs. A sociodemographic questionnaire was completed by parents at enrolment. A closeness diary was completed by each parent for 14 days to measure parental presence, involvement in infant care, holding, SSC, and emotional closeness. One question from the DigiFCC tool was sent daily via text message to the parents' cellphones to measure their perception of the quality of family-centered care they experienced. Parent depression symptoms were measured using the Edinburgh Postnatal Depression Scale at discharge.

RESULTS

A total of 60 families were involved in the study. Increased parental presence (B = 0.21, p < 0.001), increased time involved in infant care (B = 0.14, p < 0.001), increased holding time (B = 0.53, p < 0.001), and greater time in SSC (B = 0.27, p = 0.01) were associated with greater parental emotional closeness.

CONCLUSION

Several factors may enhance parents' emotional closeness when their infant is in the NICU. Care providers need to be aware and adapt their clinical practices accordingly to promote emotional closeness by encouraging parental presence, involvement in infant care, holding, and skin-to-skin contact.

Breastfeeding in Neonates Admitted to an NICU: 18-Month Follow-Up

Introduction: The admission of neonates to Neonatal Intensive Care Units (NICUs) has been identified as a primary inhibiting factor in the establishment of breastfeeding. The aims of this study were to (1) estimate the prevalence and duration of breastfeeding in infants/toddlers who had been admitted to an NICU in Greece and (2) to investigate factors, associated with the NICU stay, which affected the establishment and maintenance of breastfeeding in infants/toddlers previously admitted to the NICU. Materials and methods: Data for this cohort study were retrieved from interviews with mothers of infants/toddlers who had been admitted to our NICU as neonates during the period of 2017−2019. Interviews were conducted based on a questionnaire regarding the child’s nutrition from birth to the day of the interview, including previous maternal experience with breastfeeding. Information related to the prenatal period, gestation age, delivery mode, duration of NICU stay, and neonatal feeding strategies during their hospital stay were recorded. Results: The response rate to the telephone interviews was 57%, resulting in 279 mother−infant pairs being included in this study. The results showed that 78.1% of children received maternal milk during their first days of life. Of all infants, 58.1% were exclusively breastfed during their first month, with a gradual decrease to 36.9% and 19.4% by the end of the third and sixth months of life, respectively. The prevalence of breastfed children reached 14.7% and 7.5% at the ages of twelve and eighteen months, respectively. In the multivariate analysis, prematurity emerged as an independent prognostic factor for the duration of exclusive and any breastfeeding (aHR 1.64, 95% CI: 1.03−2.62; and 1.69, 95% CI: 1.05−2.72, respectively; p < 0.05). Additionally, the nationality of the mother, NICU breastfeeding experience, the administration of maternal milk during neonatal hospital stay, and previous breastfeeding experience of the mother were independent prognostic factors for the duration of breastfeeding. Conclusions: Although breastfeeding is a top priority in our NICU, the exclusive-breastfeeding rates at 6 months were quite low for the hospitalized neonates, not reaching World Health Organization (WHO) recommendations. Mothers/families of hospitalized neonates should receive integrated psychological and practical breastfeeding support and guidance.

An international study on implementation and facilitators and barriers for parent‐infant closeness in neonatal units

Importance

Parent‐infant closeness and active parent participation in neonatal care are important for parent and infant health.

Objective

To give an overview of current neonatal settings and gain an in‐depth understanding of facilitators and barriers to parent‐infant closeness, zero‐separation, in 19 countries.

Methods

Neonatal intensive care unit (NICU) professionals, representing 45 NICUs from a range of geographic regions in Europe and Canada, were purposefully selected and interviewed June–December 2018. Thematic analysis was conducted to identify, analyze and report patterns (themes) for parent‐infant closeness across the entire series of interviews.

Results

Parent‐infant separation during infant and/or maternity care is very common (42/45 units, 93%), despite the implementation of family integrated care (FICare) practices, including parent participation in medical rounds (17/45, 38%), structured education sessions for parents (16/45, 36%) and structured training for healthcare professionals (22/45, 49%). NICU professionals encountered four main themes with facilitators and barriers for parent‐infant closeness on and between the hospital, unit, staff, and family level: Culture (jointly held characteristics, values, thinking and behaviors about parental presence and participation in the unit), Collaboration (the act of working together between and within different levels), Capacities (resources and policies), and Coaching (education to acquire and transfer knowledge and skills).

Interpretation

Implementing parent‐infant closeness in the NICU is still challenging for healthcare professionals. Further optimization in neonatal care towards zero‐separation and parent‐infant closeness can be achieved by enforcing the ‘four Cs for Closeness’: Culture, Collaboration, Capacities, and Coaching.

Parental preference for webcams in neonatal intensive care units: an indicator of lacking trust?

Background

Some neonatal intensive care units offer parents webcam systems for times when they cannot be in the ward. Leaving an infant in the ward can be challenging for parents, and trust in the neonatal healthcare professionals mitigates parents’ worries of not knowing how their infant is doing while they are away. If parents lack trust in the neonatal healthcare professionals, they may attempt to compensate by using webcams. In this work, we examine whether an association exists between the parental preference to use a webcam and low trust in physicians and nursing staff.

Methods

In a nationwide, retrospective cross-sectional study, parents of infants with a birth weight below 1500 g were surveyed six to 18 months after their infant’s birth. Parents who were not offered a webcam system in the ward were asked whether they would have opted for it. Trust was measured by the Trust in Physician and Trust in Nursing Staff scales.

Results

Of the parents who were not offered a webcam, 69% would have chosen to use a webcam if they had been granted the opportunity. The decision for or against a webcam was not significantly associated with either trust in physicians (OR = 0.654, 95% CI = 0.456, 0.937, p = .124) or trust in nursing staff (OR = 1.064, 95% CI = 0.783, 1.446, p = .932).

Conclusions

While the majority of parents surveyed would opt for webcam usage, this preference should not be interpreted as an indicator of lacking trust in neonatal healthcare professionals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03456-2.

Parent-infant interaction in the NICU: Challenges in measurement

BACKGROUND

Parent-infant interaction is poorly understood among high-risk dyads in NICU settings. No parent-infant interaction measures are specifically designed for preterm infants within the NICU nor account for the education NICU parents receive to tailor their interactions based on the infant's cues.

AIM

To improve our understanding of a measure of parent-infant interaction in the NICU, we investigated relationships between parent-infant interaction scores on the Nursing Child Assessment Feeding Scale (NCAFS) and 1) socio-demographic and medical factors, 2) parent mental health and confidence, and 3) enhanced parental education (delivered as part of the Supporting and Enhancing NICU Sensory Experiences program) on tailoring interactions based on the infant's cues.

METHOD

Twenty-six preterm infants (born ≤32 weeks) had a video recorded oral feeding conducted by a parent in the NICU when the infant was 34-48 weeks postmenstrual age. A certified evaluator scored parent-infant interaction from the videos using the NCAFS.

RESULTS

Seventeen (65 %) parent-infant dyads scored below the 10th percentile on the total NCAFS score. Despite it being well-understood that parent-infant interaction is related to sociodemographic factors and parental mental health, there were no relationships between these factors and NCAFS scores in this study. Dyads who received enhanced parent education (n = 15) had lower NCAFS scores than dyads receiving usual care (n = 11) (p = 0.01).

CONCLUSION

It remains unclear if the standard measure of parent-infant interaction, NCAFS, captured positive and negative interactions in context of assessment of a high-risk dyad within the NICU setting. The utility of the NCAFS with preterm infants in the NICU was not supported by this study.

Social gaze in preterm infants may act as an early indicator of atypical lateralization

Visual field biases have been identified as markers of atypical lateralization in children with developmental conditions, but this is the first investigation to consider early lateralized gaze behaviors for social stimuli in preterm infants. Eye-tracking methods with 51 preterm (33 male, 92.1% White) and 61 term-born (31 male, 90.1% White) infants aged 8-10 months from Edinburgh, UK, captured the development of visual field biases, comparing gaze behavior to social and non-social stimuli on the left versus right of the screen. Preterm infants showed a significantly reduced interest to social stimuli on the left versus right compared to term children (d = .58). Preterm children exhibit early differential orienting preferences that may be an early indicator of atypical lateralized function.

Mothers' experiences of a new early collaborative intervention, the EACI, in the neonatal period: A qualitative study

AIM

To explore mothers' experiences of the EArly Collaborative Intervention.

BACKGROUND

Preterm birth puts a considerable emotional and psychological burden on parents and families. Parents to moderate and late premature infants have shorter stays at the neonatal intensive care unit and have described a need for support. The EArly Collaborative Intervention was developed to support parents with preterm infants born between gestational Weeks 30 to 36. In this study, mothers' experiences of the new intervention were explored.

DESIGN

A qualitative design guided by a reflexive thematic analysis according to Braun and Clarke. Interviews were individually performed with 23 mothers experienced with the EArly Collaborative Intervention. Data were identified, analysed and reported using reflexive thematic analysis. The COREQ checklist was used preparing the manuscript.

RESULTS

Two main overarching themes were constructed. The first theme, 'mothers' feelings evoked from the EArly Collaborative Intervention' describes the emotions raised by the intervention and how the intervention affected their parental role. Their awareness of the preterm baby's behaviour increased, and the intervention helped the parents to communicate around their baby's needs. The second theme, 'based on the preterm baby's behavior', describes experiences of the provision and the learning process about their preterm baby's needs and communication. The intervention was experienced as helpful both immediately and for future interaction with the baby.

CONCLUSIONS

Mothers found the intervention to be supportive and encouraging. They came to look upon their baby as an individual, and the new knowledge on how to care and interact with their baby affected both their own and their baby's well-being. Furthermore, the intervention felt strengthening for their relationship with the other parent.

RELEVANCE TO CLINICAL PRACTICE

The EArly Collaborative Intervention can support parents' abilities as well as their relation to their baby and may thereby contribute to infant development, cognition and well-being.

Factors associated with post NICU discharge exclusive breastfeeding rate and duration amongst first time mothers of preterm infants in Shanghai: a longitudinal cohort study

BACKGROUND

Breastfeeding is crucial for the preterm infants. Breast milk is not only food but also medicine. Few studies have focused on the longitudinal effects of exclusive breastfeeding outcome of preterm infants separated from their mothers after discharge, especially in Shanghai. We aimed to examine the exclusive breastfeeding rate and duration amongst first time mothers of preterm infants after discharge and its determinants.

METHODS

Analyses were based on 500 preterm infants separated from their mothers in a tertiary maternity and infant-specialized hospital in Shanghai from September 2018 to September 2019.The Socio-demographic characteristics, breastfeeding knowledge questionnaire, breastfeeding self-efficacy short form scale, Edinburgh postpartum depression scale and breastfeeding family support scale were used for the investigation and the exclusive breastfeeding rate of premature infants was followed up on 1 month, 3 months and 6 months after discharge. The changing trend of breastfeeding knowledge, breastfeeding self-efficacy, postpartum depression and family support were measured by ANOVA at different stages. Using the chi-square test and multiple logistic regression, factors impacting the breastfeeding rate of preterm infants at three time intervals after discharge were investigated. The Kaplan Meier survival curve and cox regression model were used to analyze the determinants of exclusive breastfeeding duration of premature infants after discharge.

RESULTS

Exclusive breastfeeding rates were 19.0, 17.2 and 10.4% at 1 month, 3 months and 6 months after discharge of preterm infants, respectively. The average length of exclusive breastfeeding duration was(3.69 ± 1.80)months. Finally, type of delivery (adjusted odds ratio [AOR] 1.564; 95% confidence interval [CI] 0.513,3.116), gestational age(AOR 0.612, 95% CI 0.236, 3.418), maternal family support (AOR 6.125,95% CI 6.359, 98.452) were discovered to be independent predictors on the exclusive breastfeeding rate at 6 months after preterm infants were discharged. Through the cox regression model, we found that a maternal planned pregnancy (HR 0.681, 95%CI 0.531,0.873), delivering breast milk during hospitalization (HR 0.797, 95%CI 0.412,2.288), NICU feeding mode during hospitalization (HR 1.221, 95%CI 0.128,1.381) and family support (HR 0.561, 95%CI 0.004,2.428) were significantly associated with the exclusive breastfeeding duration after discharge.

CONCLUSIONS

The exclusive breastfeeding outcome of premature infants was affected by many factors, so we should focus on the three levels of individual, family, society and design targeted intervention measures to increase the exclusive breastfeeding rate and prolong exclusive breastfeeding duration.

Parent Protector: Perceptions of NICU-to-Home Transition Readiness for NICU Parents of Black Preterm Infant

Black infants have twice the incidence of infant mortality (IM), death before the first birthday, and preterm birth in comparison to other US racial/ethnic groups; these factors make Black infants a high-risk group. The literature on the factors impacting caregivers and home environments for these infants is sparse. The purpose of this descriptive qualitative study was to explore perceived parental readiness to care for their Black preterm infants at home after discharge from a neonatal intensive care unit (NICU). Ten NICU parents of Black preterm infants completed a structured interview and self-report questionnaires before hospital discharge; data were analyzed using descriptive and semantic content methods. Coded parent responses were categorized as Parent Protector of Infants' Health (n = 94, 29.2%); Hindrances to Parental Readiness for Transition to Home (n = 97, 30.1%), and Parent as Partner in NICU to Home Transition (n = 131, 40.6%). All parents rated themselves "confident" (n = 6) or "very confident" (n = 4) in their ability to care for their infant after NICU discharge. Partnership with the healthcare team was described as involving health information resources, effective communication, and, most importantly, support for the parental role as infant protector for transition to home for their high-risk infant after NICU discharge.

Neonatal medical trainee doctors' perceptions and parents' self-reported needs and stressors in a surgical neonatal intensive care unit: An individualised approach

AIM

As more infants survive surgery in the newborn period for major congenital anomalies, the focus has shifted to the quality of care for parents as well as infants. In contemporary neonatal intensive care units (NICUs), doctors are encouraged to practice family-centred care and partner with parents in their infant's care. This study explored doctors' perceptions and parents' self-reported needs and stressors in a surgical NICU.

METHODS

From January 2014 to September 2015, parents of infants admitted for general surgery for a major congenital anomaly who were present in the NICU between 48 and 72 h of admission and doctors caring for their infant at the time of data collection were invited to participate. Matched data were provided using the Neonatal Family Needs Inventory and the Parental Stressor Scale:NICU.

RESULTS

Matched data for 12 doctor-parent dyads showed that doctors (neonatal medical trainees) consistently under-rated the importance of parents' needs and identified fewer of mothers' than fathers' most important needs. Doctors also consistently under-rated parents' stressors. They perceived few of fathers', but all of mothers', greatest stressors. Thematic analysis revealed four themes: infant pain management; parental autonomy; empathy; and communicating reassurance and education to parents.

CONCLUSION

The findings suggest incongruences between doctors' perceptions and parents' self-reported needs and stressors. While there is hesitation in making recommendations with this sample size, the findings highlight issues that may inform further research and contribute to a dialogue regarding the role of doctors in family-centred relationship-based models of care in the NICU.

Mother-Infant Dyadic Synchrony in the NICU Context

BACKGROUND

Dyadic synchrony is a co-constructed social process relating to the back and forth interactions between mothers and infants that are strongly associated with neurodevelopment, self-regulation, and attachment. In the neonatal intensive care unit (NICU), this process may become interrupted because of the physiological state of the infant, the emotional state of the mother, and the physical environment of the NICU.

PURPOSE

In applying Feldman's Biobehavioral Model of Synchrony, this empirical review deconstructs the process of dyadic synchrony in the NICU context and provides a conceptual approach to guide both research and clinical practice.

METHODS

First, we examine the theoretical and empirical literature to explicate the primary structural and biophysiological components of synchrony and relate these constructs to the extant research on premature infants. Next, we synthesize the maternal, infant, and contextual factors that facilitate or inhibit the ontogenesis of dyadic synchrony in the NICU. The final section highlights the state of the science in dyadic synchrony in the NICU including gaps and recommendations for future research.

FINDINGS

An empirical review synthesis presents a visual conceptual framework to illustrate multiple processes that depict maternal, infant, and contextual influences of mother-infant synchrony in the NICU.

IMPLICATIONS FOR PRACTICE/RESEARCH

Despite the challenges posed to mother-infant relationships in the NICU, high-quality mother-infant interactions are possible, dyadic synchrony can emerge, and premature infants can develop secure attachments. Clinicians and researchers can apply this conceptual framework of mother-infant dyadic synchrony in the NICU to promote evidence-based research and clinical practice.

Emotional Closeness Among NICU Fathers: A Qualitative Descriptive Study

BACKGROUND

The unique perspective of fathers with an infant in the neonatal unit on the development of emotional closeness toward their infant is not well understood. The purpose of this study is to explore experiences and instances of emotional closeness from the perspective of fathers as well as factors influencing emotional closeness during an infant's hospitalization in the neonatal unit.

METHODS

This qualitative descriptive study employed one-on-one interviews with fathers recruited in a level 3 neonatal unit. The interview data were analyzed with thematic analysis, and emerging themes and subthemes were organized according to dimensional analysis.

RESULTS

Eight fathers agreed to take part in this study. According to the participants, emotional closeness was a complex process composed of multiple dimensions. More specifically, emotional closeness was a difficult-to-describe, mixed, and growing feeling influenced by multiple factors such as the environment, co-parenting, and the father-infant relationship. It occurred in the contexts of presence and separation in the neonatal unit and was part of the development of the father-infant relationship.

IMPLICATIONS FOR PRACTICE

The results presented in this article are important for neonatal intensive care unit nurses who support fathers in the development of their fathering role. By knowing more about the process and dimensions of emotional closeness, nurses can direct their interventions with fathers to enhance emotional closeness and better understand their experience.

IMPLICATIONS FOR RESEARCH

No previous study has addressed emotional closeness as a complex process with multiple components like the current study. These findings contribute to our understanding of the process of emotional closeness for fathers.

COVID-19 lockdown impacts the wellbeing of parents with infants on a Dutch neonatal intensive care unit

PURPOSE

Parents of infants admitted to a neonatal intensive care unit (NICU) experience additional stress due to restrictions on their presence and visits by other family members during the COVID-19 pandemic. Our study aims to describe how this impacted parents and how NICU staff could support them.

DESIGN AND METHODS

This was a cross-sectional study in which 25 parents (16 mothers, 9 fathers) of infants admitted to our NICU during the first COVID-19 lockdown completed online questionnaires with socio-demographic questions, the Parental Stressor Scale:NICU (PSS:NICU) and questions related to COVID-19.

RESULTS

Being separated from, and not being able to hold their infant at all times were among the most important PSS:NICU stressors. Parents experienced additional stress because other family members were not allowed to visit. They indicated that NICU staff could support them by clearly explaining the reasons for visitor restrictions and by ensuring that they felt heard. Most parents supported the restrictions, but also mentioned that less strict measures would really help them.

CONCLUSIONS

Parents who participated in this study found it very stressful that they could not be with their infant together with their partner and other family members. Furthermore, parents recommended the hospital management to continuously reconsider whether particular restrictions could be lifted in case of a new lockdown. Together with clear communication, this would result in less parenteral stress.

PRACTICE IMPLICATIONS

Hospital management should be cautious on restricting the presence of parents and other family members and scale restrictions back whenever possible.

Alberta Family Integrated Care™ and Standard Care: A Qualitative Study of Mothers' Experiences of their Journeying to Home from the Neonatal Intensive Care Unit

Globally, one in ten infants is born preterm. Most preterm infants require care in a level II Neonatal Intensive Care Unit (NICU), which are highly technological critical care environments that can be overwhelming for parents. Alberta Family Integrated Care (AB-FICare™) is an approach to care that provides strategies to integrate parents into their infant’s care team. This sub-study is the first to compare mothers’ experiences in the context of AB-FICare™ and standard care. Semi-structured interviews with mothers from AB-FICare™ (n = 14) and standard care (n = 12) NICUs were analyzed using interpretive description informed by grounded theory methods. We identified a major theme of Journeying to Home with six categories: Recovering from Birth, Adapting to the NICU, Caring for Baby, Coping with Daily Disruption, Seeing Progress, and Supporting Parenting. Mothers in the AB-FICare™ group identified an enhancement to standard care related to building reciprocal trust with healthcare providers that accelerated Journeying to Home.

Effectiveness of Alberta Family-Integrated Care on Neonatal Outcomes: A Cluster Randomized Controlled Trial

Family-Integrated Care (FICare) empowers parents to play an active role as a caregiver for their infant in the neonatal intensive care unit (NICU). This model of care is associated with improved neonatal outcomes, such as improved weight gain and higher breastfeeding rates at discharge in infants admitted to level III NICUs; however, its effectiveness in level II NICUs remains unproven. The objective of this study was to evaluate the effectiveness of the model on neonatal outcomes in a cluster randomized controlled trial conducted in 10 level II NICUs randomized to Alberta FICare or standard care. Mothers and their preterm infants born between 32⁺⁰ and 34⁺⁶ weeks' gestational age were included. The primary outcome was the proportion of infants who regained their birth weight (BW) after 14 days of life. The analysis included 353 infants/308 mothers at Alberta FICare sites and 365 infants/306 mothers at standard care sites. There was no difference in the proportion of infants who had regained their BW by 14 days between the groups. A lack of perceived improved weight gain trajectory for those in the FICare group is attributed to a shorter length of hospital stay and infants being discharged prior to regaining BW.

Parents' Experiences of Immediate Skin-to-Skin Contact After the Birth of Their Very Preterm Neonates

OBJECTIVE

To explore parents' experiences of immediate skin-to-skin contact after the birth of their very preterm neonates and their perceptions regarding care and support from staff.

DESIGN

A descriptive qualitative study.

SETTING

Birth and neonatal units within a university hospital in Sweden.

PARTICIPANTS

Six parent couples who co-cared for their very preterm neonates with skin-to-skin contact throughout the first 6 hours after birth.

METHODS

We analyzed individual interviews using reflexive thematic analysis as described by Braun and Clarke.

RESULTS

The parents' experiences of immediate skin-to-skin contact with their very preterm neonates were represented by the following three themes: A Pathway to Connectedness, Just Being in a Vulnerable State, and Creating a Safe Haven in an Unknown Terrain. Skin-to-skin contact helped the parents attain their roles as essential caregivers and provided a calming physical sensation that promoted parents' feelings of connectedness with their newborns. When parents provide skin-to-skin contact at birth, staff members need to recognize and address their vulnerability. A good relationship with nursing staff, which was mediated through staff behaviors and availability, facilitated skin-to-skin contact.

CONCLUSION

Skin-to-skin contact initiated at birth with very preterm neonates was a valuable and empowering experience for parents and enhanced early bonding between parents and their newborns. Staff members should recognize that skin-to-skin contact between parents and neonates is an interactive process that has challenges. Future research is warranted to understand the needs of nursing staff who provide initial care in the postpartum period. Furthermore, we recommend the implementation of maternal-neonatal couplet care.

Engaging parents of hospitalized neonates during a pandemic

Background

Engaging families through patient- and family-centered care (PFCC), the NICU nurse upholds the core concepts providing holistic care. The novel coronavirus (COVID-19) pandemic altered the daily routine of visiting parents to hospitals around the nation, particularly for pediatric and neonatal populations.

Methods

This paper describes innovative strategies implemented in a large Level IV NICU to promote the core concepts of PFCC that ensured parent-infant bonding while limiting exposure to a pandemic infection, such as COVID-19.

Discussion

Strategies discussed include virtual visits between parents and infants to promote bonding; virtual parent support groups to encourage information sharing; remote music therapy options which included take-home music kits; diaries, albums, and celebration boards to support participation; among others. Parent collaboration throughout implementation promoted partnership.

Conclusion

Utilizing a variety of unique and innovative approaches to promote PFCC strategies became a critical component of routine planning and care delivery for one large neonatal intensive care unit.

The Ripple Effect of a Pandemic on the Parent-Infant Dyad

During the 2009 H1N1 pandemic, containment strategies aimed at limiting the spread of the virus were implemented but not to the extent as the current COVID-19 pandemic. Research is ongoing regarding disease symptomatology, transmission, and treatment for COVID-19. There are limited data regarding the effects of social distancing practices and restrictive hospital-visitation policies on the parent-infant dyad. The purpose of this commentary is to explore the implications of isolation practices on the parent-infant dyad during a pandemic.

Association between neonatal homecare for preterm infants and incidence of severe postpartum depression in mothers

BACKGROUND

Understanding the association between neonatal homecare and postpartum depression could contribute to the design of evidence-based interventions to prevent postpartum depression. We aimed to determine whether the change from inpatient stays in neonatal intensive care units to offering neonatal homecare was associated with a reduced incidence rate of severe postpartum depression among mothers who gave birth prematurely.

METHODS

We conducted a register-based population-wide study of all mothers who gave birth prematurely 1994-2017 to live-born infants and spent at least one night in the Neonatal Intensive Care Unit. We performed an interrupted time series analysis to investigate the incidence rate ratio of severe postpartum depression before and after the implementation of neonatal homecare. Neonatal homecare was implemented between 1994 and 2016.

RESULTS

The total population consisted of 46,456 mothers and the median age was 30 years and interquartile range of 27-34 years. Overall 4.5 % of the mothers were diagnosed with severe postpartum depression. Prior to neonatal homecare no change in the incidence of severe postpartum depression was found; (incidence rate ratio=1.01 [95 % confidence interval: 0.97-1.05] every half year, p=0.69). The implementation was associated with a level change with an incidence rate ratio reduction of 23 % (incidence rate ratio=0.77 [95 % confidence interval: 0.64-0.93], p=0.007).

LIMITATIONS

Limitations include potential underdiagnosis in early periods, lack of randomization, and different periods of implementation of neonatal homecare.

CONCLUSIONS

We found a possible association between the implementation of neonatal homecare and a 23 % reduced incidence rate of severe postpartum depression among mothers of preterm infants.

Parents' experiences of VOICE: A novel support programme in the NICU

Background

Admission of an infant to a neonatal intensive care unit (NICU) is often a stressful experience for parents and can be associated with feelings of inadequacy to fulfil the desirable parental role. The values, opportunities, integration, control, and evaluation (VOICE) programme was developed to engage parents in care, to decrease stress, and to increase empowerment.

Aim

To explore the experiences of parents regarding involvement in the VOICE programme during admission of their infant to the NICU.

Design

The VOICE programme includes at least five personal structured meetings between parents, nurses, and other health care professionals throughout the pathway from birth, NICU, and follow up. A qualitative design was adopted using semi‐structured interviews. Interviews with 13 parents of 11 infants born at <27 weeks' gestational age were conducted: nine mothers and two couples of father and mother. Thematic analysis was deployed.

Results

The findings have been described in one overarching theme: “parental empowerment.” Parents felt strengthened and were empowered in the development of their role as primary caretaker by the VOICE programme. The parental empowerment theme emerged from four related interpretive themes that were derived: (a) involvement in care, (b) personalized information and communication, (c) transition to a parental role, and (d) emotional support.

Conclusion

The VOICE programme can be a structured approach used to implement family support in a NICU to empower parents to become a partner in the care of their infant and feel confident.

Relevance to clinical practice

This study encourages health care professionals to provide parental support through a structured intervention programme, which contributes to the empowerment of parents in the NICU and encouraged them to participate in care and decision‐making.

Parents' experiences of emotional closeness to their infants in the neonatal unit: A meta-ethnography

BACKGROUND

Physical and emotional parent-infant closeness activate important neurobiological mechanisms involved in parenting. In a neonatal care context, most research focuses on physical (parental presence, skin-to-skin contact) aspects; insights into emotional closeness can be masked by findings that overemphasise the barriers or challenges to parenting an infant during neonatal care.

AIM

To explore existing qualitative research to identify what facilitates and enables parents' experiences of emotional closeness to their infants while cared for in a neonatal unit.

STUDY DESIGN

A systematic review using meta-ethnographic methods. Search strategy involved searches on six databases, author runs, and backward and forward chaining. Reciprocal translation was used to identify and compare key concepts of parent-infant emotional closeness.

RESULTS

Searches identified 6992 hits, and 34 studies from 17 countries that involved 670 parents were included. Three overarching themes and associated sub-themes were developed. 'Embodied connections' describes how emotional closeness was facilitated by reciprocal parent-infant interactions, spending time as a family, and methods for parents to feel connected while physically separated. 'Inner knowing' concerns how knowledge about infant and maternal health and understanding the norms of neonatal care facilitated emotional closeness. 'Evolving parental role' relates to how emotional closeness was intertwined with parental identities of contributing to infant health, providing direct care, and being acknowledged as a parent.

CONCLUSION

Parent-infant closeness evolves and is facilitated by multifaceted biopsychosocial factors. Practice implications include creating private and uninterrupted family time, strategies for parents to maintain an emotional connection to their infant when separated, and neurobiology education for staff.

A Randomized Trial of Continuous Versus Intermittent Skin-to-Skin Contact After Premature Birth and the Effects on Mother-Infant Interaction

BACKGROUND

Premature birth affects opportunities for interaction between infants and mothers. Skin-to-skin contact (SSC) is standard care in neonatal care but has not been sufficiently studied regarding the effects on interaction between preterm infant and mothers.

PURPOSE

The purpose of this study was to compare interaction between preterm infants and their mothers after continuous versus intermittent SSC from birth to discharge. A secondary aim was to study a potential dose-response effect between time in SSC and quality of interaction.

METHODS

Families were randomly assigned to either continuous (n = 17) or intermittent (n = 14) SSC before delivery. Interaction was measured from videotapes of a Still-Face Paradigm collected at 4 months' corrected age. Face-to-face interaction was coded according to Ainsworth's Maternal Sensitivity Scales and the Maternal Sensitivity and Responsivity Scales-R. Dose-response correlations were calculated between mean time spent in SSC and each of the interaction scales.

RESULTS

There were no statistically significant differences between groups in maternal interactive behavior toward their infants regarding sensitivity, interference, availability, acceptance, withdrawal, or intrusivity. There was no correlation between mean time in SSC and quality of interaction.

IMPLICATIONS FOR PRACTICE

Continuous SSC from birth to discharge was not superior to intermittent SSC concerning mother-infant interaction between preterm infants and their mothers at 4 months' corrected age. However, compared with other studies, mean time in SSC was also high in the intermittent group.

IMPLICATIONS FOR RESEARCH

Further studies are needed to find out how interaction between parents and preterm infants can be improved, supported, and facilitated in the neonatal intensive care unit (NICU) and whether there is an optimal dose for SSC.

Conditions for communication between health care professionals and parents on a neonatal ward in the presence of language barriers

Purpose: Family-centred neonatal care views parents and child as a unit, and aims to support each family on the basis of its specific needs. Good communication can increase parents’ satisfaction and reduce tension, and is necessary to create a mutual trustful relation, but is influenced by language barriers. We aimed to describe communication between neonatal health care professionals and parents in the presence of language barriers.

Methods: A field study using a hermeneutic lifeworld approach, participative observation, and interviews with parents and health care professionals.

Results: The main theme, endeavouring to understand the meaning behind the words, comprised three themes. Wanting to speak for oneself meant that parents wanted to speak for themselves or call on a friend or multilingual health care professionals, in contrast to the health care professionals wish to use an interpreter. Being aware of cultural keys meant that some wards had access to a “cultural broker” to assist health care professionals and parents with both language translation and understanding of the Swedish health care environment. Understanding one another in the employees’ arena reflected varying language skills among health care professionals. The health care professionals had the power to decide the level of access to communication, and decided both the intensity and the frequency of the conversations.

Conclusions: Health care professionals preferred to use an interpreter when communicating with parents, while parents wished to be independent and speak for themselves. If an interpreter was used, parents preferred this to be a friend or health care professionals; this option was less popular among health care professionals.

NICU Maternal-Infant Bonding: Virtual Visitation as a Bonding Enhancement Tool

The admission of an infant to the neonatal intensive care unit (NICU) presents specialized barriers to the maternal-infant bonding (MIB) process. Virtual visitation (VV) provides a mother with the opportunity to have continual access to her hospitalized infant via a one-way live Web camera. While increasingly used in the NICU, VV remains a novel concept. The objective of this study was to introduce a conceptual model that incorporates the use of VV into the NICU MIB process. Adapted from the Model of Mother-Infant Bonding After Antenatal HIV Diagnosis, a newly developed model of MIB using VV as a bonding enhancement tool is offered. A Model of NICU Maternal-Infant Bonding Incorporating Virtual Visitation presents the NICU bonding process in a chronological manner, with 5 primary propositions and an explanation of their related themes. Virtual visitation is introduced into the bonding process and is shown to act as a moderated variable. A Model of NICU Maternal-Infant Bonding Incorporating Virtual Visitation introduces VV as a tool to enhance the MIB process that occurs in the NICU. The model provides the basis for the development of a research program to examine the multiple potential effects of VV in the NICU.

Integration of Maternity and Neonatal Care to Empower Parents

OBJECTIVE

To describe the transition from a traditional hospital design with separate maternity and neonatal departments to a design in which maternity and neonatal health care infrastructures are integrated to empower parents.

DESIGN

A descriptive, qualitative analysis.

SETTING

A mother and child center in a teaching hospital in Amsterdam.

PARTICIPANTS

Six staff members who were involved in the transition.

METHODS

We analyzed the content of all relevant policy reports and other related documents that were produced during the transition from April 2010 to October 2014. This content was supplemented with in-depth, semistructured interviews with the six participants. We used thematic analysis and Bravo et al.'s model of patient empowerment to analyze the documents and the qualitative interview data.

RESULTS

We identified eight themes. At the health care system level, the four themes were Joint Vision and Goal, Integration of Three Wards Into One With Single-Family Rooms, Reorganization of the Health Care Team, and New Equipment. At the health care provider level, the three themes were Training for Extension of Professional Goals, Intensified Coaching for Parents, and Implementing Patient Centeredness. The single theme at the patient level was Opinions and Experiences of Parents.

CONCLUSION

We found a good fit between the new design and Bravo et al.'s model of patient empowerment. Challenges that remain include the adaptation of staff training programs and further development of the infrastructure in collaboration with staff and parents. The experiences of parents and staff members will be evaluated in future studies.

A qualitative cross-cultural analysis of NICU care culture and infant feeding in Finland and the U.S

BACKGROUND

The benefits of family-centered care for the health and well-being of preterm infants and their families include increased parent-infant closeness, improved lactation, and positive mental health outcomes; however, it is known that the extent to which family-centered care is adopted varies by unit. This study aimed to understand how differences in neonatal care culture in two units in Finland and the U.S. were translated to parents' infant feeding experiences in the hope of improving relationally focused feeding practices in both locations.

METHODS

This qualitative, cross-sectional study utilized narrative methodologies to understand the lived experiences of 15 families hospitalized in a tertiary neonatal intensive care unit in Finland (n = 8) and the U. S (n = 7).

RESULTS

A global theme of lactation as a means or an end showed that lactation and infant feeding were framed differently in each location. The three supporting themes that explain families' perceptions of their transition to parenthood, support as a family unit, and experience with lactation include: universal early postnatal challenges; culture and space-dependent nursing support; and controlled or empowering breastfeeding experiences.

CONCLUSIONS

Care culture plays a large role in framing all infant caring activities, including lactation and infant feeding. This study found that in the unit in Finland, breastfeeding was one method to achieve closeness with an infant, while in the unit in the U.S., pumping was only an end to promote infant nutritional health. Therefore, breastfeeding coupled with closeness was found to be supportive of a salutogenic, or health-promoting, care approach for the whole family.

More than words: methodological potentials of graphical elicitation with parents of preterm infants

BACKGROUND

Word-based tools, such as interviews, can only partially provide access to the lived experience of parents of preterm infants. This study explores the lived experience of parents of preterm infants between 3 and 6 months after discharge by means of visual method (i.e., graphical elicitation).

METHODS

A qualitative study with graphic elicitation analysis was used to assess the lived experience of four parental couples of very preterm infants in a home-based session occurred between 3 and 6 months after Neonatal Intensive Care Unit (NICU) discharge.

RESULTS

The use of graphical elicitation revealed three dimensions of the experience of being parents of preterm infants: 1) different use of time-lining elements suggested a different involvement of cognitive and/or emotional coping mechanisms in facing the unexpected birth and NICU stay; 2) the explicit or implicit use of emotional graphical elements and words was suggestive of different degrees of openness to disclose their experience; 3) the role of textual elements in support or substitution of graphical elements indicated different levels of integration of cognitive and emotional representations.

CONCLUSIONS

The use of visual methods holds the potentials for revealing specific aspects of the parental experience of preterm birth and NICU stay. The clinical implications of this approach are further discussed with reference to its potential implementation within parental support intervention.

Parents' presence and participation in medical rounds in 11 European neonatal units

BACKGROUND

Parents' involvement during hospital care is beneficial for preterm infants and their parents. Although parents are encouraged to be present in many neonatal intensive care units (NICUs), little is known about their role during medical rounds.

AIMS

To study parents' presence in the NICU, the degree of parents' participation during medical rounds, and to identify underlying factors for participation.

STUDY DESIGN AND SUBJECTS

A prospective study was performed in 11 neonatal units in six European countries including parents of preterm infants born before 35 gestational weeks.

OUTCOME MEASURES

Parents' presence and the degree of participation (7-point Likert scale) during medical rounds were asked using a text-message question sent to the mobile phone of each parent separately.

RESULTS

A total of 241 families were included in the study; mothers responded to 630 and fathers to 474 text-message questions, respectively. In studied units, mothers were present during medical rounds on 62.5% to 91% and fathers 30.8% to 77.8% of the days. The degree of mothers' and fathers' participation also varied between units (p < 0.001 and p = 0.022, respectively). In multivariate analysis, parents' presence increased by increasing gestational age (p = 0.010), fathers' education (p = 0.009), and by the policy in the unit to invite parents to medical rounds (p = 0.036). The background characteristics did not explain the degree of participation.

CONCLUSION

There is significant variation between neonatal units in how they include parents in medical rounds. Only few background characteristics explained the differences suggesting that unit culture plays a major role in welcoming parents to participate.

Parents' Experiences of Support in NICU Single-Family Rooms

PURPOSE

This study aimed to explore support for mothers and fathers in single-family rooms (SFRs) of a NICU.

DESIGN

A qualitative descriptive design was employed.

SAMPLE

A convenience sample of 15 parents (nine mothers, six fathers) were recruited from a Level III NICU.

METHOD

During their infants' hospitalization, each parent recorded their thoughts and feelings regarding support whenever appropriate over a period of 48 hours using Handy Application to Promote Preterm infant happY-life (HAPPY), an android recording application.

RESULTS

Parents felt supported when staff facilitated their learning in a collaborative manner, fostered their optimism, and provided situational assistance. Continuity and consistency of care and presence were important characteristics of supportive nursing care. Though SFRs offered privacy for parents to learn and to be with their infants, the design limited parental access to nursing and medical staff, which sometimes prevented parents from receiving adequate support and partaking in decision making concerning their infants' care.