Parents' experiences of information and communication in the neonatal unit about brain imaging and neurological prognosis: a qualitative study

Managing mothers' and fathers' uncertainty during their journey through early neurodevelopmental follow-up for their high-risk infants-A qualitative account

BACKGROUND

Early diagnosis of cerebral palsy is possible by 5 months corrected age for 'at-risk' infants, using diagnostic tools such as the Hammersmith Infant Neurological Examination (HINE), Prechtl's General Movements Assessment (GMA) and magnetic resonance imaging (MRI). This is an uncertain and stressful time for parents where provision of appropriate information and support is essential.

AIM

To explore parents' views and experiences in relation to the new early neurodevelopmental follow-up of 'at-risk' infants.

METHODS

Thirteen in-depth one-to-one qualitative interviews were conducted by the primary researcher, with eight parents (six mothers and two fathers) of 'at-risk' infants eligible for a follow-up clinic where the GMA and HINE were performed at 12-week corrected age. Interviews used a pre-piloted topic guide and took place before and after the clinic. Interviews were audio-recorded, transcribed verbatim and analysed using inductive coding and thematic analysis using the framework approach.

FINDINGS

Seven themes were identified: (1) attempting to manage uncertainty, (2) taking priority, (3) trusting professionals, (4) independence in the parent role, (5) feeling understood, (6) patterns of care and (7) individuality. Parents reported experiencing uncertainty about their current situation and future. Adequate preparation for and timing of information are vital. When uncertainty is poorly managed, parents' wellbeing suffers. Individual parents' perspectives and infants' developmental trajectories differ, and information should be tailored specifically for this.

CONCLUSION

A parent's understanding of the journey through neurodevelopmental care for their high risk infants is initially very limited. Implementing a counselling service for parents to access psychological support and digital reminder system for clinic appointments, as well as providing more tailored information through trusted professionals, could all improve future parents' experiences.

Prognostic Discordance Among Parents and Physicians Caring for Infants with Neurologic Conditions

OBJECTIVE

To determine the frequency, degree, and nature of prognostic discordance between parents and physicians caring for infants with neurologic conditions.

STUDY DESIGN

In this observational cohort study, we enrolled parents and physicians caring for infants with neurologic conditions in advance of a family conference. Parent-physician dyads completed a postconference survey targeting expected neurologic outcomes across 3 domains (motor, speech, and cognition) using a 6-point scale. Prognostic discordance was defined as a difference of ≥2 response options and was considered moderate (difference of 2-3 response options) or high (difference of 4-5 response options). Responses were categorized as differences in belief and/or differences in understanding using an existing paradigm.

RESULTS

Forty parent-physician dyads of 28 infants completed surveys. Parent-physician discordance about prognosis occurred in ≥1 domain in the majority of dyads (n = 28/40, 70%). Discordance was generally moderate in degree (n = 23/28, 82%) and occurred with similar frequency across all domains. Of parent-physician dyads with discordance, the majority contained a difference in understanding in at least 1 domain (n = 25/28, 89%), while a minority contained a difference of belief (n = 6/28, 21%). When discordance was present, parents were typically more optimistic in their predictions compared with physicians (n = 25/28, 89%).

CONCLUSIONS

Differing perceptions about the prognosis of critically ill infants are common and due to differences in both understanding and belief. These findings can be used to develop targeted interventions to improve prognostic communication.

Ethical considerations in the management of infants with severe intraventricular hemorrhage

Intrinsic and extrinsic factors unique to neonatal care can complicate predictions of neurological outcomes for infants who suffer from severe intraventricular hemorrhage. While care decisions are driven by the same bioethical principles used in other domains, neurological prognostication can challenge concepts of futility, require careful examination of parental values, uncover biases and/or potentially compromise the best interests of the future child. In the following chapter we will review bioethical principles and relevant concepts, explore challenges to decision-making surrounding diagnoses of severe intraventricular hemorrhage and conclude with a brief review of practical approaches for counseling parents about neurodevelopmental impairment given the constraints of prognostic uncertainty and assumptions related to quality of life. We will argue that neurological findings alone, even in the setting of severe intraventricular hemorrhage, often do not constitute enough evidence for redirection of care but can be permissible when the entire neonatal condition is considered.

Grappling with uncertainty - Experiences of parents of infants following perinatal stroke

BACKGROUND

The term perinatal stroke describes focal damage to the developing brain due to cerebrovascular disease and occurring either before or shortly after birth. Aetiology, presentation and evolution differ from stroke in adults.

AIMS

We aimed to explore early parental experiences related to having a child with perinatal stroke, including how parental psychological wellbeing had been impacted, to consider how support for families could be improved.

METHODS AND PROCEDURES

We undertook a qualitative research study, using in-depth interviews of parents of infants with perinatal stroke when the infants were 5-6 months corrected gestational age. Sixteen parents (11 female, 5 male) of 11 infants with perinatal stroke took part. Thematic analysis was used in data interpretation.

OUTCOMES AND RESULTS

Parents described distress related to the lack of information regarding likely outcome following perinatal stroke, as well as confusion around the term 'stroke'. Guilt and self-blame were expressed, with increased emotional sensitivity. Seeking information about stroke to reduce uncertainty was a useful strategy for some, but overwhelming for others.

CONCLUSIONS AND IMPLICATIONS

The diagnosis of perinatal stroke led to psychological distress in parents. Uncertainty following diagnosis produced significant emotional difficulties. Recommendations for practice include providing timely, paced information and psychological support.

Counseling parents of premature neonates on neuroimaging findings

While medical advancements have led to improved survival of extremely premature infants, children remain at risk for brain injury and neurodevelopmental impairment. Brain imaging can offer insight into an infant's acute and long-term outcome; however, counseling parents about the results and implications of brain imaging remains challenging. The purpose of this article is to review the current literature and describe the challenges associated with counseling families of premature infants on neuroimaging findings. We propose a framework to guide clinicians in counseling parents about brain imaging results, informed by best practices in other disciplines: (FIGURE): 1) Formulate a plan 2) Identify parental needs and values 3) Give information 4) Acknowledge Uncertainty 5) Recognize and Respond to emotions 6) Discuss Expectations and Establish follow-up.

Parent needs assessment instruments in neonatal intensive care units: Implications for parent education interventions

OBJECTIVES

Psychosocial and educational interventions based on standardized needs assessment can help alleviate distress among parents of premature infants. This study aims to (1) provide an overview of standardized instruments used to assess parental needs in neonatal intensive care units (NICUs) and (2) discuss their potential to facilitate the provision of appropriate support to parents of premature babies.

METHODS

A systematic literature review was conducted. PubMed, CiNAHL, PsychARTICLES, PsychINFO, and Medline were searched for studies reporting on the use of validated parental needs assessment instruments in the NICU.

RESULTS

Following the analysis of 33 publications, 6 instruments designed to assess the needs of premature infants' parents were identified. Based on their good psychometric properties and practicality, the NICU Family Needs Inventory, the Critical Care Maternal Needs Inventory, and the Nurse Parent Support Tool were considered particularly relevant for use in clinical and research settings.

CONCLUSIONS

Validated parent needs assessment instruments are available for use in the NICU setting. Further research evaluating the benefits and usability of standardized parental needs assessment in the NICU is needed.

PRACTICE IMPLICATIONS

Validated needs assessment instruments should be consistently used to facilitate the development of targeted psychosocial and educational interventions for parents in the NICU.

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.

The functions of adequate communication in the neonatal care unit: A systematic review and meta-synthesis of qualitative research

OBJECTIVE

To assess the main functions of parent-provider communication in the neonatal (intensive) care unit (NICU) and determine what adequate communication entails according to both parents and health professionals.

METHODS

A systematic review and meta-synthesis of qualitative research. PubMed, Ebsco/PsycINFO, Wiley/Cochrane Library, Ebsco/CINAHL, Clarivate Analytics/Web of Science Core Collection, and Elsevier/Scopus were searched in October-November 2019 for records on interpersonal communication between parents and providers in neonatal care. Title/abstract screening and full-text analysis were conducted by multiple, independent coders. Data from included articles were analyzed using deductive and inductive thematic analysis.

RESULTS

43 records were included. Thematic analysis of data resulted in the development of the NICU Communication Framework, including four functions of communication (1. building/maintaining relationships, 2. exchanging information, 3. (sharing) decision-making, 4. enabling parent self-management) and five factors that contribute to adequate communication across these functions (topic, aims, location, route, design) and, thereby, to tailored parent-provider communication.

CONCLUSION

The NICU Communication Framework fits with the goals of Family Integrated Care to encourage parent participation in infants' care. This framework forms a first step towards the conceptualization of (adequate) communication in NICU settings.

PRACTICE IMPLICATIONS

Findings can be used to improve NICU communication in practice, in particular through the mnemonic TAILORED.

Neuroimaging at Term Equivalent Age: Is There Value for the Preterm Infant? A Narrative Summary

Advances in neuroimaging of the preterm infant have enhanced the ability to detect brain injury. This added information has been a blessing and a curse. Neuroimaging, particularly with magnetic resonance imaging, has provided greater insight into the patterns of injury and specific vulnerabilities. It has also provided a better understanding of the microscopic and functional impacts of subtle and significant injuries. While the ability to detect injury is important and irresistible, the evidence for how these injuries link to specific long-term outcomes is less clear. In addition, the impact on parents can be profound. This narrative summary will review the history and current state of brain imaging, focusing on magnetic resonance imaging in the preterm population and the current state of the evidence for how these patterns relate to long-term outcomes.

Pregnant women's experiences and perceptions of participating in the EVERREST prospective study; a qualitative study

BACKGROUND

The EVERREST Prospective Study is a multicentre observational cohort study of pregnancies affected by severe early-onset fetal growth restriction. The study recruits women with singleton pregnancies where the estimated fetal weight is less than the 3rd centile and below 600 g, between 20 + 0 and 26 + 6 weeks of pregnancy, in the absence of a known chromosomal, structural or infective cause.

METHOD

The reported study was retrospective descriptive qualitative interview study of women who had participated in the EVERREST Prospective Study. The aim of this study was to explore the experiences and perceptions of pregnant women taking part in research during a pregnancy affected by severe early-onset fetal growth restriction. Audio-recorded semi-structured telephone interviews were conducted with a purposive sample of 12 women, at least 1 year after delivery of their baby. Two of these pregnancies had ended in stillbirth and one in neonatal death, reflecting the outcomes seen in the EVERREST Prospective Study. Participants gave informed consent, were 16 years or older and were interviewed in English. A topic guide was used to ensure a consistent approach. Questions focused on pregnancy experiences, involvement with the EVERREST study and potential involvement in future research. Recordings were transcribed verbatim for thematic analysis using NVivo10.

RESULTS

Four broad themes were identified; 'before joining the EVERREST Prospective Study', 'participating in research', 'information and support' and 'looking back and looking forwards'. Each broad theme incorporated several subthemes. All participants recalled their reaction to being told their baby was smaller than expected. The way this news was given had a lasting impact. A range of benefits of participation in the EVERREST Prospective Study were described and the participants were positive about the way it was conducted. As a consequence, they were receptive to participating in future research. However, the findings suggest that research teams should be sensitive when approaching families at a difficult time or when they are already participating in other research.

CONCLUSIONS

This study highlights the willingness of pregnant women to participate in research and identifies strategies for researchers to engage participants.

Is the diagnostic radiological image an underutilised resource? Exploring the literature

The number of diagnostic imaging examinations being undertaken in the UK is rising. Due to the expensive nature of producing these examinations and the risks associated with exposing living tissue to the ionising radiation used by many of the imaging techniques, this growth comes with both a financial and a human cost.

In a time of limited resources, it is important that we are able to maximise the benefits which we extract from these resources. Therefore, a broad search of the current literature was undertaken to assess our current understanding of the nature of benefit available from diagnostic radiological images.

Two broad categories of benefit were identified: primary benefit (n = 470) and secondary benefit (n = 49). Primary benefits are those which are related to the justification for undertaking the imaging, e.g., abnormality detection, to assist in diagnosis or staging, or acting as an aid to clinical decision making, or intervention. Secondary benefits are those that are not related to the justification for imaging, e.g., to promote patient engagement and understanding or to facilitate communication.

Existing work considering primary benefits is comprehensive. Secondary benefit, however, is less well recognised and may not be reliably realised. Use of the image to realise these benefits has far-reaching potential. Particularly, there may be underexplored benefits which access to the images may provide to patients. This represents a gap in existing research which should be addressed.

Exploring parent expectations of neonatal therapeutic hypothermia

OBJECTIVE

We aimed to assess the parent experience of therapeutic hypothermia (TH), specifically focusing on unmet expectations.

STUDY DESIGN

Open-ended questions were used in a focus group setting. We employed an inductive approach to develop thematic content from the transcribed recordings.

RESULTS

30 parents of infants treated with TH participated. Within the principal theme of managing expectations, four sub-themes emerged. These included parental concerns about morphine use; specifically the association of morphine with end-of-life care and addiction. Parents perceived their role as key in the decision to implement TH and were emotionally burdened by this during and after TH. Parents recall intense fear for the infant's immediate survival and were not sufficiently reassured regarding survival. Parents also experience ongoing uncertainties about the long-term prognosis after TH.

CONCLUSION

The identification of these four areas in which parents have unmet expectations is important in order to improve the delivery of care.

Advanced neuroimaging and its role in predicting neurodevelopmental outcomes in very preterm infants

Up to 35% of very preterm infants survive with neurodevelopmental impairments (NDI) such as cognitive deficits, cerebral palsy, and attention deficit disorder. Advanced MRI quantitative tools such as brain morphometry, diffusion MRI, magnetic resonance spectroscopy, and functional MRI at term-equivalent age are ideally suited to improve current efforts to predict later development of disabilities. This would facilitate application of targeted early intervention therapies during the first few years of life when neuroplasticity is optimal. A systematic search and review identified 47 published studies of advanced MRI to predict NDI. Diffusion MRI and morphometry studies were the most commonly studied modalities. Despite several limitations, studies clearly showed that brain structural and metabolite biomarkers are promising independent predictors of NDI. Large representative multicenter studies are needed to validate these studies.

Qualitative study of the clinician-parent interface in discussing prognosis following MRI and US imaging of preterm infants in the UK

OBJECTIVE

To explore communication and interaction between parents and clinicians following neonatal ultrasound (US) and MRI of the brain of babies born preterm.

SETTING

This qualitative study was undertaken as part of a larger UK study of neonatal brain imaging. 511 infants were cared for in 14 London neonatal units with MR and cerebral US imaging in a specialist centre.

PARTICIPANTS

Parents with infants born at <33 weeks gestation were randomised to receive prognostic information based on either MRI or US findings on their infants at term-corrected age.

METHODS

Discussions between parents and clinicians about the MRI or US result were audio recorded. Parents were told about the findings and their baby's predicted outcome. A topic guide ensured essential aspects were covered. Recordings were fully transcribed. Discussion of the scan results, the content and style of the interaction and parental response were analysed qualitatively in 36 recordings using NVivo V.10.

OUTCOMES

Key themes and subthemes were identified in the clinician-parent discussions.

RESULTS

The overarching theme of 'the communication interface' was identified with three key themes: 'giving information', 'managing the conversation' and 'getting it right' and further subthemes. A range of approaches were used to facilitate parental understanding and engagement. There were differences in the exchanges when information about an abnormal scan was given. The overall structure of the discussions was largely similar, though the language used varied. In all of the discussions, the clinicians talked more than the parents.

CONCLUSIONS

The discussions represent a difficult situation in which the challenge is to give and receive complex prognostic information in the context of considerable uncertainty. The study highlights the importance of being able to re-visit specific issues and any potential areas of misunderstanding, of making time to talk to parents appreciating their perspective and level of knowledge.

TRIAL REGISTRATION NUMBER

EudraCT 2009-013888-19; Pre-results.

Communication Challenges in Neonatal Encephalopathy

BACKGROUND

Families must process complex information related to neonatal encephalopathy and therapeutic hypothermia.

METHODS

In this mixed methods study, semi-structured interviews were performed with parents whose infants were enrolled in an existing longitudinal cohort study of therapeutic hypothermia between 2011 and 2014.

RESULTS

Thematic saturation was achieved after 20 interviews. Parental experience of communicating with clinicians was characterized by 3 principle themes. Theme 1 highlighted that a fragmented communication process mirrored the chaotic maternal and neonatal course. Parents often received key information about neonatal encephalopathy and therapeutic hypothermia from maternal clinicians. Infant medical information was often given to 1 family member (60%), who felt burdened by the responsibility to relay that information to others. Families universally valued the role of the bedside nurse, who was perceived as the primary source of communication for most (75%) families. Theme 2 encompassed the challenges of discussing the complex therapy of therapeutic hypothermia: families appreciated clinicians who used lay language and provided written material, and they often felt overwhelmed by technical information that made it hard to understand the "big picture" of their infant's medical course. Theme 3 involved the uncertain prognosis after neonatal encephalopathy. Parents appreciated specific expectations about their infant's long-term development, and experienced long-term distress about prognostic uncertainty.

CONCLUSIONS

Communicating complex and large volumes of information in the midst of perinatal crisis presents inherent challenges for both clinicians and families. We identified an actionable set of communication challenges that can be addressed with targeted interventions.

Explanations and information-giving: clinician strategies used in talking to parents of preterm infants

Background

The study is part of a larger research programme on neonatal brain imaging in the trial element of which parents were randomised to receive prognostic information based upon either magnetic resonance imaging (MRI) or ultrasound findings (ePrime study). The aim of this study was to investigate the strategies used by clinicians in communicating with parents following imaging at term age of the brain of preterm infants born before 33 weeks gestation, focusing on explanations and information-giving about prognosis 

Method

Audio recordings of discussions between parents and clinicians were made following MRI and ultrasound assessment. Parents were given the scan result and the baby’s predicted prognosis. A framework was developed based on preliminary analysis of the recordings and findings of other studies of information-giving in healthcare. Communication of scan results by the clinicians was further explored in qualitative analysis with 36 recordings using NVivo 10 and the specifically developed framework. Emerging themes and associated sub-themes were identified.

Results

The ways in which clinicians gave information and helped parents to understand were identified. Within the over-arching theme of clinician strategies a wide range of approaches were used to facilitate parental understanding. These included orienting, checking on previously acquired information, using analogies, explaining terminology, pacing the information, confirming understanding, inviting clarification, answering parents’ questions and recapping at intervals. Ultimately four key themes were identified: ‘Framing the information-giving’, ‘What we are looking at’, ‘Presenting the numbers and explaining the risk’ and ‘Appreciating the position of parents’.

Conclusions

The interviews represent a multifaceted situation in which there is a tension between the need to explain and inform and the inherent complexity of neurological development, potential problems following preterm birth and the technology used to investigate and monitor these.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-016-0561-6) contains supplementary material, which is available to authorized users.

Informing and educating parents about the risks and outcomes of prematurity

The current process of educating and informing parents of the concerns and outcomes of premature infants is suboptimal, mostly because of modifiable factors. Proven methods to improve the transference of information are underused. In most institutions, the task to inform and educate parents is left to individual providers. Effective parent-clinician communication depends collectively on parents, clinicians, and the health care systems. Efforts must focus on improving communication and not on decreasing information provided to parents. If done successfully, we might find new and worthy allies in the trenches of the NICU.

The role of neuroimaging in predicting neurodevelopmental outcomes of preterm neonates

Magnetic resonance imaging (MRI) is a safe and high-resolution neuroimaging modality that is increasingly used in the neonatal population to assess brain injury and its consequences on brain development. It is superior to cranial ultrasound for the definition of patterns of both white and gray matter maturation and injury and therefore has the potential to provide prognostic information on the neurodevelopmental outcomes of the preterm population. Furthermore, the development of sophisticated MRI strategies, including diffusion tensor imaging, resting state functional connectivity, and magnetic resonance spectroscopy, may increase the prognostic value, helping to guide parental counseling and allocate early intervention services.

The effect of person-centred communication on parental stress in a NICU: a randomized clinical trial

AIM

To investigate the effect of the Guided Family-Centred Care intervention, developed by the lead author, on parental stress in a neonatal intensive care unit (NICU).

METHODS

Parents (n = 134) of infants born ≤34 weeks gestational age were randomly assigned to a standard care group (n = 60) or intervention group (n = 74) between April 2011 and August 2012. Guided Family-Centred Care components used were as follows: scheduled nurse-parent dialogues, semi-structured reflection sheets and person-centred communication. Parental stress was assessed at discharge using parent-reported outcomes on the Nurse Parent Support Tool and the Parental Stressor Scale: Neonatal Intensive Care Unit.

RESULTS

The total stress scores reported by parents did not vary significantly between the intervention and standard groups, with a mean (SD) of 2.70 (0.67) versus 2.84 (0.71), respectively. However, the confidence interval included the prespecified clinical significance level. Subscale and Nurse Parent Support Tool scores did not differ between the groups. Overall, mothers reported more stress than fathers (p < 0.001).

CONCLUSION

Our study was unable to demonstrate the effect of person-centred communication using the Guided Family-Centred Care intervention. It may be necessary to replicate the design to address the risk of contamination and add instruments sensitive to human interaction.