The Perinatal-Neonatal Care Journey for Parents of Preterm Infants: What Is Working and What Can Be Improved

Maternal Stress Experience in the Neonatal Intensive Care Unit after Preterm Delivery

OBJECTIVE

 Preterm delivery with the admission of a child in the neonatal intensive care unit (NICU) is extremely challenging for parents. Being separated from the baby and seeing her infant feeling pain and being sick together with the complexity of the NICU environment, the mother experiences great anxiety, fear, and stress. The purpose of the study was to assess NICU-related stress and to identify maternal and infant factors associated with increased stress in mothers of preterm infants.

STUDY DESIGN

 The maternal stress level was assessed in 122 mothers of preterm infants using the Parental Stressor Scale: NICU (PSS: NICU) in which items were distributed in three subscales as follows: Sights and Sounds of NICU-subscale 1 (S1), Infant Appearance and Behavior-S2, and Parental Role Alteration-S3.

RESULTS

 Maternal total PSS: NICU score was 3.46 ± 0.71. Parenteral Role Alteration was the most stressful (4.20 ± 0.79) followed by Infant Appearance and Behavior (3.51 ± 0.91) and Sights and Sounds subscale (2.28 ± 0.95); p (S1-S2) < 0.001, p (S1-S3) < 0.001, and p (S2-S3) < 0.001. Total PSS: NICU and Infant Appearance and Behavior scores correlated positively with maternal age (r = 0.189; p = 0.040 and r = 0.204; p = 0.027, respectively) and duration of NICU treatment (r = 0.188; p = 0.044 and r = 0.190; p = 0.042). More visits in NICU by a mother were associated with a lower PSS: NICU score (p = 0.049) and neonatal seizures and invasive ventilation in infants were associated with higher stress scores (p = 0.007 and p = 0.042).

CONCLUSION

 Mothers of preterm infants admitted in the NICU experience significant stress which is correlated with maternal age and NICU treatment duration and is associated with frequency of NICU visits, presence of neonatal seizures, and need for ventilator support. Parental role alteration is the greatest stressor followed by Infant Appearance and Behavior and NICU-surrounding stressor factors which show the need for interventions and counseling focused on mothers' role, their involvement in infant's care, and thus, family-centered care implementation.

KEY POINTS

· Mothers of preterm infants experience significant stress.. · Parental role alteration is the greatest maternal stressor.. · Maternal stress is correlated with age and NICU duration, and is associated with the frequency of NICU visits and infant's health status.

Factors associated with posttraumatic stress and anxiety among the parents of babies admitted to neonatal care: a systematic review

BACKGROUND

Posttraumatic stress (PTS) and anxiety are common mental health problems among parents of babies admitted to a neonatal unit (NNU). This review aimed to identify sociodemographic, pregnancy and birth, and psychological factors associated with PTS and anxiety in this population.

METHOD

Studies published up to December 2022 were retrieved by searching Medline, Embase, PsychoINFO, Cumulative Index to Nursing and Allied Health electronic databases. The modified Newcastle-Ottawa Scale for cohort and cross-sectional studies was used to assess the methodological quality of included studies. This review was pre-registered in PROSPERO (CRD42021270526).

RESULTS

Forty-nine studies involving 8,447 parents were included; 18 studies examined factors for PTS, 24 for anxiety and 7 for both. Only one study of anxiety factors was deemed to be of good quality. Studies generally included a small sample size and were methodologically heterogeneous. Pooling of data was not feasible. Previous history of mental health problems (four studies) and parental perception of more severe infant illness (five studies) were associated with increased risk of PTS, and had the strongest evidence. Shorter gestational age (≤ 33 weeks) was associated with an increased risk of anxiety (three studies) and very low birth weight (< 1000g) was associated with an increased risk of both PTS and anxiety (one study). Stress related to the NNU environment was associated with both PTS (one study) and anxiety (two studies), and limited data suggested that early engagement in infant's care (one study), efficient parent-staff communication (one study), adequate social support (two studies) and positive coping mechanisms (one study) may be protective factors for both PTS and anxiety. Perinatal anxiety, depression and PTS were all highly comorbid conditions (as with the general population) and the existence of one mental health condition was a risk factor for others.

CONCLUSION

Heterogeneity limits the interpretation of findings. Until clearer evidence is available on which parents are most at risk, good communication with parents and universal screening of PTS and anxiety for all parents whose babies are admitted to NNU is needed to identify those parents who may benefit most from mental health interventions.

A Systematic Review of Psycho-Spiritual Interventions in the NICU: Supporting Parents' Mental Health and Psychological Well-Being

BACKGROUND

The presence of psychospiritual supports and interventions for neonatal intensive care unit (NICU) parents is unclear.

PURPOSE

This systematic review examines the psychological and medical literature for psychospiritual interventions designed to support parents' mental health and psychological well-being during or after the NICU experience.

DATA SOURCES

Data sources include PubMed, PsycINFO, and Cochrane Library (Cochrane Database of Systemic Reviews, Cochrane Central Register of Controlled Trials) with peer-reviewed studies published between 2013 and 2023.

STUDY SELECTION

Peer-reviewed studies that included spiritual and psychological intervention components focused on supporting parents during or after the NICU were included for this systematic review. There were 42 records located in 3 databases ultimately yielding 4 peer-reviewed studies that met inclusion criteria. Articles must have been written in English and evaluate parents'/caregivers' mental health/psychological well-being in relation to a psychospiritual intervention.

DATA EXTRACTION

Because of the small number of studies, article summaries are provided within the results section and were written by the first author with approval by the second and third authors.

RESULTS

Results indicated that when psychological (focus on coping) and spiritual components were included psychological and well-being outcomes were better for NICU parents.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The inclusion of psychological and spiritual aspects of coping and supportive care is necessary for the best family-centered NICU care. More work needs to be done to develop psychospiritual supports and include fathers in these endeavors as most work occurs with mothers. Nurses need support and training to facilitate family-centered care with a focus on parents' psychospiritual needs.

Safe care for premature babies at home: Parenting and stimulating development

Parental daily care and adequate stimuli are extremely important for development and safety of premature babies at home. This study aimed to analyze safe home care for babies born under 32 weeks from parents' perspectives, with a view to a longitudinal promotion of baby development. A qualitative study, based on philosophical hermeneutic approach proposed by Hans-Georg Gadamer, in which dialogue as a principle provides understanding and fusion of experiences and knowledge. Semi-structured interviews were conducted with 18 parents of premature babies under 1 year of age. Thematic analysis proposed by Braun and Clarke was applied using an inductive approach. Elements related to safe care were identified: home arrival, safe home care: preserving baby health and development, support for safe home care, and development of parental care to promote baby safety. These elements can provide a basis for safe home care that needs to be reinforced longitudinally to increase particularities of baby protection, avoid accidents and illnesses, and improve appropriate developmental stimuli and positive parenting.

Transition in the Context of Parental Participation in Caring for Infants in Neonatal Intensive Care Units: An Evolutionary Concept Analysis

While participating in the care for a baby in a neonatal intensive care unit, parents experience a transition in which they adapt to changes and reconstruct their roles and identities. However, there is no clear explanation for this concept of transition. The purpose of this study was to clarify this concept using Rodgers' evolutionary approach. The identified attributes of the concept were a process of learning, repeated undulating emotions, balancing a caring relationship with nurses, and embracing new roles and responsibilities. The findings can provide a knowledge base for future research aimed at enhancing nurses' understanding of transition and promoting parental participation.

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.

Measuring experience of and satisfaction with newborn care: a scoping review of tools and measures

BACKGROUND

Standardised measures on experience of care are essential to understanding the care women and newborns receive and to designing appropriate interventions and responses. This review builds on ongoing work in the realm of maternity care and complements it by reviewing existing tools and measures to assess experience of and satisfaction with the care of the newborn.

METHODS

We conducted a scoping review of published literature to identify measures and tools of experience (physiological or indirect) and satisfaction with newborn care. We systematically searched five bibliographic databases from 1 January 2010 through 1 December 2022 and contacted professional networks. Using a predefined evidence template, we extracted data on the studies and the tools' characteristics. We mapped the tools and measures against the WHO quality of care frameworks to identify the most frequent measured domains of care and to highlight existing gaps.

RESULT

We identified 18 292 records of which 72 were eligible. An innovative finding of this review is the inclusion of newborn perspectives through behavioural responses, physiological signals, pain profiles as well as other non-verbal cues as markers of newborn experience. Domains related to parental participation and decision-making, ensuring continuity of care and receiving coordinated care, were the most measured across the included tools.

CONCLUSION

Comprehensive and validated instruments measuring all aspects of care are needed. Developing a robust theoretical ground will be fundamental to the design and utilisation of standardised tools and measures.

PROTOCOL REGISTRATION DETAILS

This review was registered and published on protocol.io (dx.doi.org/10.17504/protocols.io.bvk7n4zn).

Parent Survey Identifies Low-Cost Emotional and Educational Supports in NICU and Beyond

BACKGROUND

Families face significant mental health challenges after preterm birth. However, there are few low-cost and sustainable services to help with mental health challenges.

PURPOSE

To understand suggestions for low-cost and sustainable mental health supports to help families.

METHODS

This was an internet-based survey made available to preterm families through the Canadian Premature Babies Foundation social media (Facebook private parents' group).

RESULTS

Families reported that peer support, such as connecting with other parents and families who experience preterm birth, was most beneficial. Parents also reported ways to allow families to access the existing mental health services, such as providing child care options and improving advertisement of available resources.

IMPLICATIONS

Our results can help implement beneficial low-cost and sustainable mental health supports across many contexts (eg, hospitals and community organization) both in-person and online.

How parents and health professionals experience prematurity in an Italian neonatal intensive care: A grounded theory study

PURPOSE

The aim of this study was to explore prematurity as a psycho-social process from the point of view of both parents and healthcare professionals.

DESIGN AND METHODS

We conducted a Grounded Theory study through semi-structured interviews. Participants were from an Italian Neonatal Intensive Care Unit, including parents of premature children, and health professionals. Interviews were analyzed according to Grounded Theory coding strategies, to hypothesize a theoretical model.

RESULTS

On one side, behaviors, emotions, and feelings of parental couples; on the other one, the activities and reactions of professionals have been interpreted in a four-phase negotiated process: 1) the initial breakup; 2) the floating family; 3) the event processing; 4) the reconstruction of a new family.

CONCLUSIONS

Managing prematurity is a negotiated process which could be better managed through a family-centered approach as fundamental in neonatal and pediatric services. Being open in listening, coherent in the given answers, and knowing the entire process and story of being suddenly parents of a premature child can make the difference in the future definition of a new family.

PRACTICE IMPLICATIONS

Perinatal care would benefit from the following suggested practical implications: i) reducing feelings of separation and solitude by integrating diverse professionals around the family systems; ii) expediting prematurity-related changes through peer-support during hospitalization and attention to rooms' organization; iii) enhancing information exchange between all professionals involved in the care of dyads/parents and new-borns, starting since the pregnancy and continuing after the child's birth by implementing multidisciplinary meetings or appropriate care pathways.

Designing a Mobile Health Solution to Facilitate the Transition from NICU to Home: A Qualitative Study

There is limited information about caregiver and provider perspectives regarding the design of a mobile health solution to facilitate the transition from the neonatal intensive care unit (NICU) to home. Focus groups were conducted with English- or Spanish-speaking families enrolled in an urban high-risk infant follow-up clinic and with their care providers. We generated salient themes using an inductive thematic analysis. Twenty-two participants completed the study. Among caregivers, the infant's median gestational age (IQR) was 29 (23, 34) weeks and 63% were Hispanic. Among the providers, 55% had practiced for more than 10 years and 18% were bilingual. Key stakeholder (family and provider) priorities for designing a mobile health solution were organized into eight domains, i.e., implementation ideas around user interface and timing, providing path planning and information, increasing support, improving engagement with providers and services, mitigating barriers to care after discharge and strengthening parenting role and confidence. The results from this study suggest that families and healthcare providers prioritize path planning, information and support as the pillars for designing an effective NICU-to-home transition mobile health application. Implications for product development include family empowerment, being a credible source of information and creating a resource for caregiver support and mental health.

Association of a Family Integrated Care Model With Paternal Mental Health Outcomes During Neonatal Hospitalization

IMPORTANCE

During newborn hospitalization in the neonatal unit, fathers often feel anxious and excluded from their child's caregiving and decision-making. Few studies and interventions have focused on fathers' mental health and their participation in neonatal care.

OBJECTIVE

To study the association of a family integrated care (FICare) model (in single family rooms with complete couplet-care for the mother-newborn dyad) vs standard neonatal care (SNC) in open bay units with separate maternity care with mental health outcomes in fathers at hospital discharge of their preterm newborn and to study whether parent participation was a mediator of the association of the FICare model on outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, multicenter cohort study was conducted from May 2017 to January 2020 as part of the fAMily Integrated Care in the Neonatal Ward Study, at level-2 neonatal units in the Netherlands (1 using the FICare model and 2 control sites using SNC). Participants included fathers of preterm newborns admitted to participating units. Data analysis was performed from January to April 2021.

EXPOSURE

FICare model in single family rooms with complete couplet-care for the mother-newborn dyad during maternity and/or neonatal care.

MAIN OUTCOMES AND MEASURES

Paternal mental health was measured using the Parental Stress Scale: NICU, Hospital Anxiety and Depression Scale, Post-partum Bonding Questionnaire, Perceived (Maternal) Parenting Self-efficacy Scale, and satisfaction with care (EMpowerment of PArents in THe Intensive Care-Neonatology). Parent participation (CO-PARTNER tool) was assessed as a potential mediator of the association of the FICare model with outcomes with mediation analyses (prespecified).

RESULTS

Of 309 families included in the fAMily Integrated Care in the Neonatal Ward Study, 263 fathers (85%) agreed to participate; 126 fathers were enrolled in FICare and 137 were enrolled in SNC. In FICare, 89 fathers (71%; mean [SD] age, 35.1 [4.8] years) responded to questionnaires and were analyzed. In SNC, 93 fathers (68%; mean [SD] age, 36.4 [5.5] years) responded to questionnaires and were analyzed. Fathers in FICare experienced less stress (adjusted β, -10.02; 95% CI, -15.91 to -4.13; P = .001) and had higher participation scores (adjusted odds ratio, 3.424; 95% CI, 0.860 to 5.988; P = .009) compared with those in SNC. Participation mediated the beneficial association of the FICare model with fathers' depressive symptoms (indirect effect, -0.051; 95% CI, -0.133 to -0.003) and bonding with their newborns (indirect effect, -0.082; 95% CI, -0.177 to -0.015).

CONCLUSIONS AND RELEVANCE

These findings suggest that the FICare model is associated with decreased paternal stress at discharge and enables fathers to be present and participate more than SNC, thus improving paternal mental health. Supporting fathers to actively participate in all aspects of newborn care should be encouraged regardless of architectural design of the neonatal unit.

Family integrated care: very preterm neurodevelopmental outcomes at 18 months

OBJECTIVE

To examine whether the family integrated care (FICare) programme, a multifaceted approach which enables parents to be engaged as primary caregivers in the neonatal intensive care unit, impacts infant neurodevelopment and growth at 18 months' corrected age.

DESIGN/METHODS

Prospective cohort study of infants born <29 weeks' gestational age (GA) who participated in the FICare cluster randomised control trial (cRCT) and were assessed in the Canadian Neonatal Follow-Up Network (CNFUN). The primary outcome measure, Cognitive or Language composite score <85 on the Bayley-III, was compared between FICare exposed and routine care children using logistic regression, adjusted for potential confounders and employing generalised estimation equations to account for clustering of infants within sites.

RESULTS

Of 756 infants <29 weeks' GA in the FICare cRCT, 505 were enrolled in CNFUN and 455 were assessed (238 FICare, 217 control). Compared with controls, FICare infants had significantly higher incidence of intraventricular haemorrhage (IVH) (19.5% vs 11.7%, p=0.024) and higher proportion of employed mothers (76.6% vs 73.6%, p=0.043). There was no significant difference in the odds of the primary outcome (adjusted OR: 0.92 (0.59 to 1.42) FiCare vs Control) on multivariable analyses adjusted for GA, IVH and maternal employment. However, Bayley-III Motor scores (adjusted difference in mean (95% CI) 3.87 (1.22 to 6.53) and body mass index 0.67 (0.36 to 0.99) were higher in the FICare group.

CONCLUSIONS

Very preterm infants exposed to FICare had no significant difference in incidence of cognitive or language delay but had better motor development.

TRIAL REGISTRATION NUMBER

Participants in this cohort study were previously enrolled in a registered trial: NCT01852695.

Research on the Application Value of Intelligent Heating Box in Newborn Nursing

The aim of this study was to explore the application effect of intelligent incubator in neonatal care. We selected the period from January 1, 2018, to December 31, 2020, where there were 100 full-term and premature babies born in a hospital and transferred to the neonatal intensive care unit (NICU) within 1 hour after birth. Before the improved heat preservation, 100 full-term infants in the control group and 100 full-term infants in the intervention group of the intelligent warming box were formed into a full-term infant group for a comparative study. Statistics and comparison of the two groups of term infants and premature infants admitted to the hospital were carried out to assess body temperature and the changes in the incidence of each system. The research found that on comparison of admission body temperature between the control group and the intervention group, with the intervention group in the intelligent heating box, the incidence of hypothermia was significantly lower than that of the control group (95% vs. 37% of full-term infants; 98% vs. 49% of premature babies; there is a statistical significance (P < 0.05)). The intelligent heating box can reduce the fluctuation of the newborn's body temperature, keep the internal environment of newborns stable, and provide suitable conditions for the rapid growth of newborns, suitable for clinical promotion and application.

Barriers to Transition to Home From the Neonatal Intensive Care Unit: A Qualitative Perspectives of Parents and Healthcare Providers

The objective of this study was to explore the challenges faced by parents of former neonatal intensive care unit (NICU) patients in transitioning home from parents' and healthcare providers' perspective. We conducted semistructured individual and group interviews with parents of former NICU patients and healthcare providers. Themes from the individual interviews framed the group interviews' contents. The group interviews were recorded and transcribed, and thematic analysis was performed to identify themes. We conducted individual and group interviews with 16 parents and 33 inpatient and outpatient providers from November 2017 to June 2018. Individual interview participants identified several barriers experienced by parents when transitioning their infant home from the NICU including parental involvement and engagement during NICU stay and during the discharge process. Further exploration within group interviews revealed opportunities to improve discharge communication and processes, standardization of parental education that was lacking due to NICU resource constraints, support for parents' emotional state, and use of technology for infant care in the home. Parents of NICU patients face serious emotional, logistical, and knowledge challenges when transitioning their infant home from the NICU. Understanding and mitigating the challenges of transitioning infants from NICU to home require multistakeholder input from both parents and providers.

Support needs of parents in neonatal intensive care unit: An integrative review

BACKGROUND

Having an infant in the neonatal intensive care unit (NICU) is associated with intense emotional stress for both mothers and fathers. However, with the right support from staff, this stress can be reduced significantly. Although evidence on needs of parents in the neonatal unit exists, there is lack of a systematic integrative review on the support needs of parents in the neonatal unit. Current review evidence is needed to support busy neonatal unit clinicians in their practice.

AIM AND OBJECTIVES

The purpose of this integrative review is to explore the current available evidence to describe and understand the support needs of parents of infants in the NICU.

METHODS

The integrative review process of Whittemore and Knafl (2005) was used to guide this study. Six databases-MEDLINE, CINHAL, PubMed, Scopus, Google Scholar and PsycINFO-were searched for eligible studies using relevant keywords. Primary studies published in English language from 2010 to 2021 were reviewed following a pre-determined inclusion criteria. Studies that met the inclusion criteria were critically appraised using the Mixed Methods Appraisal Tool (MMAT). The review report is guided by the PRISMA 2020 checklist for systematic reviews.

RESULTS

Overall, 24 primary qualitative, quantitative and mixed methods studies were included in the review. Analysis of included studies resulted in six themes that demonstrate the support needs of parents in the NICU; 1. Information needs; 2. Emotionally intelligent staff; 3. Hands-on support; 4. Targeted support; 5. Emotional needs; and 6. Practical needs.

CONCLUSION

This review has presented the current evidence on the needs of parents from their own perspective. Healthcare workers' understanding and supporting these needs in the NICU is likely to increase parental satisfaction and improve health outcomes for parents, infants and their family.

RELEVANCE TO CLINICAL PRACTICE

Parents of infants in the NICU require staff support to enhance their experiences, well-being, caring and parenting confidence during admission and post-discharge. As parents are in constant need for informational, emotional and practical support, continuing professional development for NICU staff should place emphasis on effective communication strategies, enhancing emotional intelligence and empathy among staff. NICU staff should build positive ongoing relationships with parents and provide targetted support for mothers and fathers.

Effects of parent-provider communication during infant hospitalization in the NICU on parents: A systematic review with meta-synthesis and narrative synthesis

OBJECTIVE

To synthesize and analyse the literature on the effects of parent-provider communication during infant hospitalization in the neonatal (intensive) care unit (NICU) on parent-related outcomes.

METHODS

Systematic review with meta-synthesis and narrative synthesis. Databases (PubMed, PsycINFO, Cochrane Library, CINAHL, Web of Science, Scopus) were searched in October/November 2019. Studies reporting, observing, or measuring parent-related effects of parent-provider communication in the NICU were included. Study quality was assessed using the Quality Assessment Tool for Studies with Diverse Designs. Qualitative studies were meta-synthesized using deductive and inductive thematic analysis. Quantitative studies were analysed using narrative synthesis.

RESULTS

5586 records were identified; 77 were included, reporting on N = 6960 parents, N = 693 providers, and N = 300 NICUs. Analyses revealed five main (positive and negative) effects of parent-provider interaction on parents' (1) coping, (2) knowledge, (3) participation, (4) parenting, and (5) satisfaction. Communication interventions appeared impactful, particularly in reducing parental stress and anxiety. Findings confirm and refine the NICU Communication Framework.

CONCLUSIONS

Parent-provider communication is a crucial determinant for parental well-being and satisfaction with care, during and following infant hospitalization in the NICU. R. Practice Implications: Providers should particularly consider the impact on parents of their day-to-day interaction - the most occurring form of communication of all.

Preterm Labor and Birth: A Clinical Review

When caring for women experiencing preterm labor and birth, nurses play a significant role as bedside experts, advocates, patient educators, and key members of the maternity care team. Enhanced expertise on clinical and professional knowledge of preterm labor and birth is crucial in prevention and treatment. As preterm birth rates continue to rise, perinatal nurses as well-informed clinical experts have the opportunity to offer innovative education, holistic assessments, and communication through shared decision-making models. Educating pregnant women about early recognition of preterm labor warning signs and symptoms allows for timely diagnosis, interventions, and treatment. Informed and collaborative nursing practice improves quality of clinical care based on individualized interactions. A clinical review of preterm labor and preterm birth is presented for perinatal nurses.

Understanding preparation for preterm infant discharge from parents' and healthcare providers' perspectives: Challenges and opportunities

AIM

To describe the facilitating/inhibiting factors of preparation for preterm infant discharge and recommendations for increasing discharge readiness from parents' and healthcare providers' perspectives based on Meleis's Transitions Theory.

DESIGN

A qualitative cross-sectional descriptive design.

METHODS

We selected a purposive sample of 17 parents (9 fathers and 8 mothers) and 13 healthcare providers (10 nurses and 3 clinicians) from the neonatal intensive care unit of a tertiary hospital in Eastern China. Data were collected between May -July 2018. Data from audio-recorded semi-structured individual interviews were coded with content analysis both inductively and deductively.

RESULTS

The analyses yielded four themes: personal conditions, community conditions, nursing therapeutics, and patterns of response. Parents and healthcare providers had unique opinions about the themes.

CONCLUSION

Meleis's Transitions Theory seems to be an applicable and practicable framework for understanding the discharge preparation of parents with preterm infants and may be used to help healthcare providers to develop appropriate interventions on discharge preparation practice.

IMPACT

To address the lack of discharge readiness of preterm infants in China and countries with a similar clinical context, healthcare providers should help parents play a more active role to promote their engagement in discharge preparation. In a wider global community, healthcare providers should consider parents' personal conditions and their practical needs in performing discharge preparation.

Parent experience of caring for neonates with seizures

OBJECTIVE

Neonates with seizures have a high risk of mortality and neurological morbidity. We aimed to describe the experience of parents caring for neonates with seizures.

DESIGN

This prospective, observational and multicentre (Neonatal Seizure Registry) study enrolled parents of neonates with acute symptomatic seizures. At the time of hospital discharge, parents answered six open-ended response questions that targeted their experience. Responses were analysed using a conventional content analysis approach.

RESULTS

144 parents completed the open-ended questions (732 total comments). Four themes were identified. Sources of strength: families valued medical team consensus, opportunities to contribute to their child's care and bonding with their infant. Uncertainty: parents reported three primary types of uncertainty, all of which caused distress: (1) the daily uncertainty of the intensive care experience; (2) concerns about their child's uncertain future and (3) lack of consensus between members of the medical team. Adapting family life: parents described the many ways in which they anticipated their infant's condition would lead to adaptations in their family life, including adjusting their family's lifestyle, parenting approach and routine. Many parents described financial and work challenges due to caring for a child with medical needs. Emotional and physical toll: parents reported experiencing anxiety, fear, stress, helplessness and loss of sleep.

CONCLUSIONS

Parents of neonates with seizures face challenges as they adapt to and find meaning in their role as a parent of a child with medical needs. Future interventions should target facilitating parent involvement in clinical and developmental care, improving team consensus and reducing the burden associated with prognostic uncertainty.

Historical Perspectives: Unsilencing Suffering: Promoting Maternal Mental Health in Neonatal Intensive Care Units

Mothers of infants in the NICU suffer higher rates of psychological distress, anxiety, and depression compared with the general population. Often, their mental health concerns remain underidentified and undertreated, which can have deleterious effects on the offspring, both in short-term outcomes while in the NICU as well as long-term neurodevelopmental and behavioral outcomes. In this review, we present an overview of existing empirical evidence about how maternal mental health affects the health of infants, special considerations regarding the mental health needs of NICU mothers, and the findings about existing and developing interventions to address mental health concerns in this vulnerable population.

Addressing the Needs of Mothers with Infants in the Neonatal Intensive Care Unit: A Qualitative Secondary Analysis

PURPOSE

Mothers of infants hospitalized in neonatal intensive care units (NICUs) need to be recognized as essential partners of the care team as their presence and involvement are key to infants' health and developmental outcomes. Addressing mothers' perceived needs is beneficial for the improvement of supportive nursing care; however, little qualitative research on their unmet needs has been conducted in South Korea. This study assessed mothers' perspectives on their NICU experiences and their unmet needs within the South Korean cultural context.

METHOD

A cross-sectional, multicentered, secondary analysis study was conducted using the written responses to an open-ended questionnaire. Of the 344 NICU-experienced mothers, 232 throughout South Korea (seven cities and five provinces) voluntarily completed the questionnaire via smartphone-based or web-based surveys. Their narrative responses were analyzed using thematic content analysis guided by the critical incident technique.

RESULTS

Four themes emerged. NICU-experienced mothers of preterm infants referred to the "family-friendly environment" (16.4%) as a positive experience. The greatest unmet need was "relationship-based support" (58.2%), followed by "information and education-based support" (20.0%) and "system-level challenges" (5.4%).

CONCLUSION

The importance of creating a family-friendly NICU environment should be emphasized by ensuring 24-hour unrestricted access and encouraging active parental involvement in infant care, as well as actively supporting NICU families through supportive words and actions. The assurance of antiinfection management and better staffing levels should be fundamentally guaranteed to NICU staff.

Safety and efficacy of probiotic administration to preterm infants: ten common questions

In spite of a large number of randomized placebo-controlled clinical trials and observational cohort studies including >50,000 preterm infants from 29 countries that have demonstrated a decrease in the risk of necrotizing enterocolitis, death, and sepsis, routine prophylactic probiotic administration to preterm infants remains uncommon in much of the world. This manuscript reflects talks given at NEC Society Symposium in 2019 and is not intended to be a state-of-the-art review or systematic review, but a summary of the probiotic-specific aspects of the symposium with limited additions including a recent strain-specific network analysis and position statement from the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN). We address ten common questions related to the intestinal microbiome and probiotic administration to the preterm infant.

Finnish Parents' Responsibilities for Their Infant's Care When They Stayed in a Single Family Room in a Neonatal Intensive Care Unit

PURPOSE

To describe parents' perceptions of their responsibilities for their infant's care during admission to a single family room in a neonatal intensive care unit (NICU).

DESIGN AND METHODS

A qualitative study with semi-structured individual interviews conducted at a family-centered level III Finnish NICU in late 2016 and early 2017. The participants were 10 mothers and nine fathers of infants aged from six days to eight months. The data were analyzed with inductive content analysis.

RESULTS

The parents wanted to take responsibility for their infant's care during their stay in a single family room in the NICU, because it prepared them for their infant's discharge. The mothers and fathers reported that their responsibilities supported them as they grew into parenthood and enabled their infants' rights. On the other hand, the parents needed nurses to empower them to commit to, and take, responsibility for their infant's care and share decision making. The nurses also taught the parents caring skills.

CONCLUSIONS

Empowering parents to take responsibility enabled their infant's rights during their stay in a single family room in the NICU. More research is needed about how nurses transfer these responsibilities to parents and how those are connected to the infant's rights and well-being.

PRACTICE IMPLICATIONS

Organizations who provide single family rooms in NICUs need to develop guidelines that facilitate the responsibilities that parents and nurses have to care for the infants. Although parents are the infant's primary caregivers, they depend on nurses to ensure their infant is safely cared for.

Family Integrated Care for Preterm Infants

Parent-infant separation is a major source of stress for parents of hospitalized preterm infants and has negative consequences for infant health and development. Family Integrated Care (FICare) uses a strengths-based approach, based on family-centered care principles to promote parental empowerment, learning, shared decision making, and positive parent-infant caregiving experiences. Outcomes of FICare include increased self-efficacy upon discharge and improved parent-infant relationships and infant developmental outcomes. In this article, the authors describe the FICare model and emerging evidence regarding outcomes of FICare for infants and families and discuss challenges and opportunities in implementing and maintaining high-quality FICare.

Training attention control of very preterm infants: protocol for a feasibility study of the Attention Control Training (ACT)

BACKGROUND

Children born preterm may display cognitive, learning, and behaviour difficulties as they grow up. In particular, very premature birth (gestation age between 28 and less than 32 weeks) may put infants at increased risk of intellectual deficits and attention deficit disorder. Evidence suggests that the basis of these problems may lie in difficulties in the development of executive functions. One of the earliest executive functions to emerge around 1 year of age is the ability to control attention. An eye-tracking-based cognitive training programme to support this emerging ability, the Attention Control Training (ACT), has been developed and tested with typically developing infants. The aim of this study is to investigate the feasibility of using the ACT with healthy very preterm (VP) infants when they are 12 months of age (corrected age). The ACT has the potential to address the need for supporting emerging cognitive abilities of VP infants with an early intervention, which may capitalise on infants' neural plasticity.

METHODS/DESIGN

The feasibility study is designed to investigate whether it is possible to recruit and retain VP infants and their families in a randomised trial that compares attention and social attention of trained infants against those that are exposed to a control procedure. Feasibility issues include the referral/recruitment pathway, attendance, and engagement with testing and training sessions, completion of tasks, retention in the study, acceptability of outcome measures, quality of data collected (particularly, eye-tracking data). The results of the study will inform the development of a larger randomised trial.

DISCUSSION

Several lines of evidence emphasise the need to support emerging cognitive and learning abilities of preterm infants using early interventions. However, early interventions with preterm infants, and particularly very preterm ones, face difficulties in recruiting and retaining participants. These problems are also augmented by the health vulnerability of this population. This feasibility study will provide the basis for informing the implementation of an early cognitive intervention for very preterm infants.

TRIAL REGISTRATION

Registered Registration ID: NCT03896490. Retrospectively registered at Clinical Trials Protocol Registration and Results System (clinicaltrials.gov).

Evaluating the effect of Family Integrated Care on maternal stress and anxiety in neonatal intensive care units

Objective: To identify how Family Integrated Care (FICare) affected maternal stress and anxiety. Study Design: This secondary analysis of the FICare cluster randomised controlled trial included infants born between 1 April 2013 and 31 August 2015 at ≤33 weeks' gestation. Mothers completed the PSS:NICU and STAI questionnaires at enrolment and study day 21. Results: 1383 mothers completed the surveys at one or both time-points. The mean PSS:NICU and STAI scores at day 21 were significantly lower in the FICare mothers than controls (PSS:NICU mean [standard deviation] FICare 2.32 [0.75], control 2.48 [0.78], p = 0.0005; STAI FICare 70.8 [20.0], control 74.2 [19.6], p = 0.0004). The sights and sounds, looks and behaviour, and parental role PSS:NICU subscales and the state and trait STAI subscales were all significantly different between FIC are and controls at day 21. The magnitude of change in all stress and anxiety subscales was greater in the FICare group than controls. These differences remained significant after adjustment for confounders with the greatest change in the parental role (least-squares mean [95% confidence interval] FICare -0.65 [-0.72, 0.57], control -0.31 [-0.38, -0.24], p < 0.0001) and state anxiety subscales. Conclusion: FICare is effective at reducing NICU-related maternal stress and anxiety.

Viewpoints from families for improving transition from NICU-to-home for infants with medical complexity at a safety net hospital: a qualitative study

Background

We have limited information on families’ experiences during transition and after discharge from the neonatal intensive care unit.

Methods

Open-ended semi-structured interviews were conducted with English or Spanish- speaking families enrolled in Medicaid in an urban high-risk infant follow up clinic at a safety-net center, which serves preterm and high-risk term infants. We generated salient themes using inductive-deductive thematic analysis.

Results

Twenty-one participants completed the study. The infant’s median (IQR) birth weight was 1750 (1305, 2641) grams; 71% were Hispanic and 10% were Black non-Hispanic; 62% reported living in a neighborhood with 3-4th quartile economic hardship. All were classified as having chronic disease per the Pediatric Medical Complexity Algorithm and 67% had medical complexity. A conceptual model was constructed and the analysis revealed major themes describing families’ challenges and ideas to support transition centered on the parent-child role and parent self-efficacy. The challenges were: (1) comparison to normal babies, (2) caregiver mental health, (3) need for information. Ideas to support transition included, (1) support systems, (2) interventions using mobile health technology (3) improved communication to the primary care provider and (4) information regarding financial assistance programs. Specific subthemes differed in frequency counts between infants with and without medical complexity.

Conclusions

Families often compare their preterm or high-risk infant to their peers and mothers feel great anxiety and stress. However, families often found hope and resilience in peer support and cited that in addition to information needs, interventions using mobile health technology and transition and financial systems could better support families after discharge.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1604-6) contains supplementary material, which is available to authorized users.

The evolution of family-centered care: From supporting parent-delivered interventions to a model of family integrated care

There is increasing recognition that parents play a critical role in promoting the health outcomes of low birthweight and preterm infants. Despite a large body of literature on interventions and models to support family engagement in infant care, parent involvement in the delivery of care for such infants is still restricted in many neonatal intensive care units (NICUs). In this article, we propose a taxonomy for classifying parent-focused NICU interventions and parent-partnered care models to aid researchers, clinical teams, and health systems to evaluate existing and future approaches to care. The proposed framework has three levels: interventions to support parents, parent-delivered interventions, and multidimensional models of NICU care that explicitly incorporate parents and partners in the care of their preterm or low birthweight infant. We briefly review the available evidence for interventions at each level and highlight the strong level of research evidence to support the parent-delivered intervention of skin-to-skin contact (also known as the Kangaroo Care position) and for the Kangaroo mother care and family integrated care models of NICU care. We suggest directions for future research and model implementation to improve and scale-up parent partnership in the care of NICU infants.

Arguments for routine administration of probiotics for NEC prevention

PURPOSE OF REVIEW

Probiotic administration to premature infants for the purpose of prevention of necrotizing enterocolitis is common in many parts of the world but uncommon in the United States. The present review will emphasize recent findings in support of routine administration of probiotics to this highly vulnerable population.

RECENT FINDINGS

Additional evidence from animal models describing mechanisms of protection of probiotics in the immature gut and updated meta-analyses of randomized placebo-controlled trials and observational cohorts are presented (now including more than 40 000 premature infants from countries across the globe).

SUMMARY

The preponderance of evidence suggests that probiotic administration to premature infants is well tolerated and decreases the risk of death, necrotizing enterocolitis, and sepsis. Further comparisons of probiotic administration to placebo are not likely to alter these conclusions. Rather, future work should focus on assurance of high-quality products with demonstrated purity and viability of probiotic microbes, and future clinical trials should focus on comparisons between high-quality products and doses.

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.

Experiences of Mothers of Extremely Preterm Infants after Hospital Discharge

PURPOSE

The purpose of this study was to describe and understand the experiences of mothers of extremely preterm infants during the first twelve months at home following discharge from a neonatal intensive care unit.

DESIGN AND METHODS

A qualitative, interpretative approach using Gadamer's philosophical hermeneutics was carried out. One focus group and fifteen in-depth, semi-structured interviews were conducted twelve months after hospital discharge. Responses were recorded, transcribed and analyzed using computer-assisted qualitative data analysis.

RESULTS

The study´s participants were twenty women. The following themes emerged from the data analysis: 1) 'The journey home: the discharge process', which included the sub-themes 'escaping the hospital environment: between desire and fear' and 'preparing parents for hospital discharge: practice and formal support'; and 2) 'The difficulty of living with an extremely preterm infant', including the sub-themes 'the challenge of an unexpected form of childcare', 'overprotection of and bond with a child with special needs' and 'disturbance in the social/familiar setting: when a mother becomes a nurse'.

CONCLUSIONS

The process of hospital discharge and the first months at home are difficult. The birth and care of an extremely preterm infant affect the mothers' quality of life as well as their family and social life. Practice and early discharge programmes can make the discharge process easier.

PRACTICE IMPLICATIONS

The knowledge and understanding of the experience of mothers of extremely preterm infants in the first months at home after hospital discharge could help healthcare professionals to develop educational strategies and counselling interventions in accordance with the mothers' needs.

Understanding parents' emotional experiences for neonatal education: A narrative, interpretive approach

AIMS AND OBJECTIVES

To explore the emotional experiences of parents who have had premature babies to inform and educate neonatal nurses and health professionals in this field.

BACKGROUND

Parents find the neonatal unit a daunting and unfamiliar place leading to anxiety, uncertainty and fear about the future of their baby. Parents have significant emotional needs in relation to assisting them to cope with their neonatal experience. In line with a family-centred approach to neonatal education, it is essential to teach health professionals about the emotional impact of neonatal care based on an appreciation of the parent experience.

DESIGN

A narrative-based, interpretive approach was undertaken in line with constructivist learning theory.

METHODS

Twenty narrative interviews took place, with a total of 23 parents of premature babies. Following core story creation to create coherent stories from the raw transcripts, thematic analysis of the narrative constructs using the principles of Braun and Clarke's, International Journal of Qualitative Studies on Health and Well-Being, 2014, 9, 1, framework was undertaken. The study methods were compliant with the consolidated criteria for reporting qualitative research (COREQ).

FINDINGS

Thematic analysis revealed key themes relating to the following: parents' emotions through the whole neonatal experience, feelings towards the baby, the environment, the staff and the transitions through the different phases of neonatal care. Both negative and positive experiences were reported.

CONCLUSION

Understanding the emotional experience from the parent's perspective, following birth of their premature baby, informs empathic, family-centred teaching and learning within the neonatal education arena.

RELEVANCE TO CLINICAL PRACTICE

Students and health professionals alike can learn what is important in the delivery of care that addresses the emotional needs of parents and families. Educators can use narratives and key messages from parents, both negative and positive, to teach family-centred principles to nurses and health professionals as a core component of a narrative curricula and potentially to enhance empathy.

Depression, posttraumatic stress and relationship distress in parents of very preterm infants

To determine the prevalence, associated factors, and relationships between symptoms of depression, symptoms of posttraumatic stress (PTS), and relationship distress in mothers and fathers of very preterm (VPT) infants (< 32 weeks). Mothers (n = 323) and fathers (n = 237) completed self-report measures on demographic and outcome variables at 38 days (SD = 23.1, range 9-116) postpartum while their infants were still hospitalised. Of mothers, 46.7% had a moderate to high likelihood of depression, 38.1% had moderate to severe symptoms of PTS, and 25.1% were in higher than average relationship distress. The corresponding percentages in fathers were 16.9, 23.7, and 27%. Depression was positively associated with having previous children (p = 0.01), speaking little or no English at home (p = 0.01), financial stress (p = 0.03), and recently accessing mental health services (p = 0.003) for mothers, and financial stress (p = 0.005) and not being the primary income earner (p = 0.04) for fathers. Similar associations were found for symptoms of PTS and relationship distress. Being in higher relationship distress increased the risk of depression in both mothers (p < .001) and fathers (p = 0.03), and PTS symptoms in mothers (p = 0.001). For both mothers and fathers, depression was associated with more severe PTS symptoms (p < .001). Fathers of VPT infants should be screened for mental health problems alongside mothers, and postpartum parent support programs for VPT infants should include strategies to improve the couple relationship.

Parents' views on preparation to care for extremely premature infants at home

AIM

To gain insight into the post-discharge experiences of parents in relation to the adequacy of preparation for caring for extremely premature infants at home.

METHOD

A narrative approach was drawn on to facilitate data collection, through face-to-face semi-structured interviews with 14 parents of extremely premature infants.

FINDINGS

Constant comparative analysis was used to allow the emergence of five key research themes - emotional and mental health of parents, uncertain outcomes, ongoing health needs of the baby, educational needs of health professionals, and parental support and preparation for transition home.

CONCLUSION

Parental experience of being discharged home with a premature baby can be emotionally challenging and necessitates a range of support mechanisms to help them to cope with this period of transition. Health professionals can direct parents to appropriate counselling services, resources and peer support groups. Tailored education is needed for community-based health professionals, such as health visitors, to equip them to support parents practically and emotionally during the transition home and beyond. In addition, health professionals can learn much from parents about what is needed to support them.

Finding My Way: A Phenomenology of Fathering in the NICU

BACKGROUND

Historically, the relationship between infant and mother in the neonatal intensive care unit (NICU) has been the main focus of parenting research, leaving a gap in the literature regarding the paternal experience.

PURPOSE

The purpose of this study was to gain an understanding of the lived experience of fathering an infant born at less than 28 weeks' gestation admitted to a level III NICU.

METHODS

Seven fathers of premature infants (25-27 weeks' gestation) participated in a semistructured interview about the experience of becoming a father to a premature infant at least 1 to 2 weeks after the NICU admission. Data were collected in 2015.

FINDINGS

The primary themes identified were looking in, persevering, holding, and finding my way. Fathers in this study described feeling like an outsider in the NICU while learning to trust strangers, protect the mother and the child, and continue to work and provide for the family. Holding for the first time is pivotal in this journey, as the moment of solidifying the connection with the child.

IMPLICATIONS FOR PRACTICE

The findings from this study bring awareness of the experiences of fathers during the NICU journey of having a premature infant. Nurses should encourage paternal participation and involvement, visitation, and facilitate kangaroo care opportunities early and often.

IMPLICATIONS FOR RESEARCH

The findings from this study allow nurses to better understand the paternal experience of having a premature infant born at less than 28 weeks. However, future research should continue to investigate the paternal experience with other gestational ages as well as the influence of stress of fathers during this experience.

Health care experiences of pregnant, birthing and postnatal women of color at risk for preterm birth

BACKGROUND

Chronic stress is a known risk factor for preterm birth, yet little is known about how healthcare experiences add to or mitigate perceived stress. In this study, we described the pregnancy-related healthcare experiences of 54 women of color from Fresno, Oakland, and San Francisco, California, with social and/or medical risk factors for preterm birth.

METHODS

This study was a secondary analysis of focus group data generated as part of a larger project focused on patient and community involvement in preterm birth research. English and Spanish speaking women, age 18 or greater with social and/or medical risk factors for preterm birth participated in two focus groups, six weeks apart. Data from the first focus groups are included in this analysis.

RESULTS

Five themes emerged from thematic analysis of the transcripts. Participants described disrespect during healthcare encounters, including experiences of racism and discrimination; stressful interactions with all levels of staff; unmet information needs; and inconsistent social support. Despite these adverse experiences, women felt confidence in parenting and newborn care. Participant recommendations for healthcare systems improvement included: greater attention to birth plans, better communication among multiple healthcare providers, more careful listening to patients during clinical encounters, increased support for social programs such as California's Black Infant Health, and less reliance on past carceral history and/or child protective services involvement.

DISCUSSION

The women in this study perceived their prenatal healthcare as a largely disrespectful and stressful experience. Our findings add to the growing literature that women of color experience discrimination, racism and disrespect in healthcare encounters and that they believe this affects their health and that of their infants.

Online information for parents caring for their premature baby at home: A focus group study and systematic web search

Background

Online resources are a source of information for parents of premature babies when their baby is discharged from hospital.

Objectives

To explore what topics parents deemed important after returning home from hospital with their premature baby and to evaluate the quality of existing websites that provide information for parents post‐discharge.

Methods

In stage 1, 23 parents living in Northern Ireland participated in three focus groups and shared their information and support needs following the discharge of their infant(s). In stage 2, a World Wide Web (WWW) search was conducted using Google, Yahoo and Bing search engines. Websites meeting pre‐specified inclusion criteria were reviewed using two website assessment tools and by calculating a readability score. Website content was compared to the topics identified by parents in the focus groups.

Results

Five overarching topics were identified across the three focus groups: life at home after neonatal care, taking care of our family, taking care of our premature baby, baby's growth and development and help with getting support and advice. Twenty‐nine sites were identified that met the systematic web search inclusion criteria. Fifteen (52%) covered all five topics identified by parents to some extent and 9 (31%) provided current, accurate and relevant information based on the assessment criteria.

Conclusion

Parents reported the need for information and support post‐discharge from hospital. This was not always available to them, and relevant online resources were of varying quality. Listening to parents needs and preferences can facilitate the development of high‐quality, evidence‐based, parent‐centred resources.

Parent-Infant Closeness, Parents' Participation, and Nursing Support in Single-Family Room and Open Bay NICUs

This was a prospective survey study, comparing parent-infant closeness, parents' perceptions of nursing support, and participation in medical rounds in single-family room (SFR) and an open bay (OB) neonatal intensive care units. Nurses' assessments of provided support were also measured. In total, 115 parents of 64 preterm infants less than 35 weeks' gestational age and 129 nurses participated. Parents recorded the presence and skin-to-skin care. Parents were sent 9 text message questions in random order. Nurses answered corresponding Internet-based questions. SFR mothers were more present, 20 hours daily (median) versus 7 hours (P < .001), initiated skin-to-skin contact (SSC) at 4 versus 12 hours (P = .03), and preformed SSC 180 min/24 h versus 120 min/24 h for mothers in the OB unit (P = .02). SFR fathers were also more present, 8 versus 4 hours (P < .001), initiated SSC at 3 versus 40 hours (P = .004), and performed SSC 67 min/24 h versus 31 min/24 h (P = .05). SFR parents rated participation in medical rounds and emotional support higher than OB parents. Parental trust was rated higher by nurses in the OB unit (P = .02). SFR facilitated parent-infant closeness, parents' participation in medical rounds, and increased support from nurses.