Development and psychometric evaluation of the CO-PARTNER tool for collaboration and parent participation in neonatal care

Evaluation of a new tool - "Step by step with my baby" - to support parental involvement in the care of preterm infants

BACKGROUND AND AIMS

Parental guidance is essential for supporting parental involvement, maintaining the quality and safety of infant care, and limiting parental stress. The efficiency of a new tool to support parental empowerment - "Step by step with my baby" - was evaluated. The perception of this tool by parents and nurses was studied.

METHODS

This was a prospective, observational study conducted from September 2019 to December 2020 at a level-3 neonatal center. A total of 79 newborns (<33 weeks of gestational age or small for gestational age), 84 parents, and 94 nurses were included. The new tool that was evaluated is in the form of a drawing of flowers to be colored according to the parents' ability to care for their newborn. Six domains were explored and given a score (total of 35 points) according to the parents' ability to care for each item: behavior, skin-to-skin contact, carrying, oral and tube feeding, and routine care. The use and relevance of this tool were evaluated by parents and caregivers.

RESULTS

At a mean of 19 days of life, parents required caregiver support regardless of the skill domain (6/35). After 26 days, the mean score increased to 19.4 (p < 0.05). Parents felt autonomous in changing diapers and monitoring temperature but always required help for skin-to-skin contact, carrying, and feeding with or without a tube. The progression was not affected by the presence of siblings, the distance from home, and staying in the parental hospital room. For 67 % of the parents, the tool gave them a better understanding of their newborn and helped them be more confident (69 %) without feeling judged (81 %). These feelings were upheld by nurses.

CONCLUSIONS

This tool was efficient for evaluating parents' autonomy and helped them take ownership of the care provided.

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

AIM

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

DESIGN

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

METHODS

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

DATA SOURCES

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS

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

IMPACT

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

FINDINGS

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

IMPACT

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Parent-led neonatal pain management-a narrative review and update of research and practices

Introduction

Research related to parent-led neonatal pain management is increasing, as is the clinical implementation. Skin-to-skin contact, breastfeeding and parents' vocalizations are examples of pain reducing methods that give parents an opportunity to protect their infant from harm while alleviating their anxiety and developing their parenting skills.

Methods

In this paper we will provide a narrative review and describe the current research about parent-led neonatal pain management. Based on this we will discuss clinical challenges, implementation strategies and implications for future research.

Results

Parents express great readiness to embrace opportunities to increase their self-efficacy in their ability to address infant pain. Parent-led pain-reducing methods are effective, feasible, cost-effective, culturally sensitive, and can be individualized and tailored to both the parent's and infant's needs. Both barriers and facilitators of parent-led pain care have been studied in research highlighting structural, organizational, educational, and intra- and interpersonal aspects. For example, health care professionals' attitudes and beliefs on parent-led methods, and their concern that parental presence during a procedure increases staff anxiety. On the other hand, the presence of a local pain champion whose duty is to facilitate the adoption of pain control measures and actively promote parent-professional collaboration, is crucial for culture change in neonatal pain management and nurses have a key role in this change. The knowledge-to-practice gap in parent-led management of infants' procedure-related pain highlight the need for broader educational applications and collaborative professional, parental and research initiatives to facilitate practice change.

Conclusion

Parent-led neonatal pain management is more than simply a humane and compassionate thing to do. The inclusion of parent-led pain care has been scientifically proven to be one of the most effective ways to reduce pain associated with repeated painful procedures in early life and parents report a desire to participate. Focus on enablers across interprofessional, organizational and structural levels and implementation of recommended pediatric pain guidelines can support the provision of optimal evidence-based family-centered neonatal pain management.

NICU Couplet Care: metrics to guide an evolving model of care

OBJECTIVE

The evidence-based science of maternal and neonatal care has been rapidly changing. As a result, clinical practice and the design of physical space have evolved in order to provide neuroprotection for the baby and meet expectations of family presence and participation.

SETTING

The concept and practice of NICU Couplet Care supports positive health well-being/outcomes and early relationship building between the mother-baby-father/partner.

RESULTS

Monitoring evidence-based measures and metrics of standardized care, performance competence, neuro-physical and psychosocial outcomes, environmental design, family and staff satisfaction, and sustainability are essential to the evolution of quality, safe, efficient, effective, ethical, and cost-effective care for the mother, baby, and family. Transparency in the dissemination of evidence, practice standards, and outcome data is important to guide parents/families and health professionals in making informed shared decisions regarding the clinical care provided and the environment where care takes place.

Multidimensional assessment of infant, parent and staff outcomes during a family centered care enhancement project in a tertiary neonatal intensive care unit: study protocol of a longitudinal cohort study

BACKGROUND

The therapeutic advances and progress in the care for preterm infants have enabled the regular survival of very immature infants. However, the high burden of lifelong sequelae following premature delivery constitutes an ongoing challenge. Regardless of premature delivery, parental mental health and a healthy parent-child relationship were identified as essential prerogatives for normal infant development. Family centered care (FCC) supports preterm infants and their families by respecting the particular developmental, social and emotional needs in the Neonatal Intensive Care Unit. Due to the large variations in concepts and goals of different FCC initiatives, scientific data on the benefits of FCC for the infant and family outcome are sparse and its effects on the clinical team need to be elaborated.

METHODS

This prospective single centre longitudinal cohort study enrols preterm infants ≤ 32 + 0 weeks of gestation and/or birthweight ≤ 1500 g and their parents at the neonatal department of the Giessen University Hospital, Giessen, Germany. Following a baseline period, the rollout of additional FCC elements is executed following a stepwise 6-months approach that covers the NICU environment, staff training, parental education and psychosocial support for parents. Recruitment is scheduled over a 5.5. year period from October 2020 to March 2026. The primary outcome is corrected gestational age at discharge. Secondary infant outcomes include neonatal morbidities, growth, and psychomotor development up to 24 months. Parental outcome measures are directed towards parental skills and satisfaction, parent-infant-interaction and mental health. Staff issues are elaborated with particular focus on the item workplace satisfaction. Quality improvement steps are monitored using the Plan- Do- Study- Act cycle method and outcome measures cover the infant, the parents and the medical team. The parallel data collection enables to study the interrelation between these three important areas of research. Sample size calculation was based on the primary outcome.

DISCUSSION

It is scientifically impossible to allocate improvements in outcome measures to individual enhancement steps of FCC that constitutes a continuous change in NICU culture and attitudes covering diverse areas of change. Therefore, our trial is designed to allocate childhood, parental and staff outcome measures during the stepwise changes introduced by a FCC intervention program.

TRIAL REGISTRATION

Clinicaltrials.gov, trial registration number NCT05286983, date of registration 03/18/2022, retrospectively registered, http://clinicaltrials.gov .

Improving Neonatal Intensive Care Unit Quality and Safety with Family-Centered Care

There is strong evidence that family-centered care (FCC) improves the health and safety of infants and families in neonatal settings. In this review, we highlight the importance of common, evidence-based quality improvement (QI) methodology applied to FCC and the imperative to engage in partnership with neonatal intensive care unit (NICU) families. To further optimize NICU care, families should be included as essential team members in all NICU QI activities, not only FCC QI activities. Recommendations are provided for building inclusive FCC QI teams, assessing FCC, creating culture change, supporting health-care practitioners and working with parent-led organizations.

Patient engagement practice within perinatal eHealth: A scoping review

BACKGROUND

There is a gap in knowledge about how perinatal eHealth programs function to support autonomy for new and expectant parents from pursuing wellness goals.

OBJECTIVES

To examine patient engagement (access, personalization, commitment and therapeutic alliance) within the practice of perinatal eHealth.

DESIGN

Scoping review.

METHODS

Five databases were searched in January 2020 and updated in April 2022. Reports were vetted by three researchers and included if they documented maternity/neonatal programs and utilized World Health Organization (WHO) person-centred digital health intervention (DHI) categories. Data were charted using a deductive matrix containing WHO DHI categories and patient engagement attributes. A narrative synthesis was conducted utilizing qualitative content analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses 'extension for scoping reviews' guidelines were followed for reporting.

RESULTS

Twelve eHealth modalities were found across 80 included articles. The analysis yielded two conceptual insights: (1) The nature of perinatal eHealth programs: (1) emergence of a complex structure of practice and (2) practising patient engagement within perinatal eHealth.

CONCLUSION

Results will be used to operationalize a model of patient engagement within perinatal eHealth.

Parents' Experiences of Communication in Neonatal Care (PEC): a neonatal survey refined for real-time parent feedback

OBJECTIVE

Assessing parent experiences of neonatal services can help improve quality of care; however, there is no formally evaluated UK instrument available to assess this prospectively. Our objective was to refine an existing retrospective survey for 'real-time' feedback.

METHODS

Co-led by a parent representative, we recruited a convenience sample of parents of infants in a London tertiary neonatal unit. Our steering group selected questions from the existing retrospective 61-question Picker survey (2014), added and revised questions assessing communication and parent involvement. We established face validity, ensuring questions adequately captured the topic, conducted parent cognitive interviews to evaluate parental understanding of questions,and adapted the survey in three revision cycles. We evaluated survey performance.

RESULTS

The revised Parents' Experiences of Communication in Neonatal Care (PEC) survey contains 28 questions (10 new) focusing on communication and parent involvement. We cognitively interviewed six parents, and 67 parents completed 197 PEC surveys in the survey performance evaluation. Missing entries exceeded 5% for nine questions; we removed one and format-adjusted the rest as they had performed well during cognitive testing. There was strong inter-item correlation between two question pairs; however, all were retained as they individually assessed important concepts.

CONCLUSION

Revised from the original 61-question Picker survey, the 28-question PEC survey is the first UK instrument formally evaluated to assess parent experience while infants are still receiving neonatal care. Developed with parents, it focuses on communication and parent involvement, enabling continuous assessment and iterative improvement of family-centred interventions in neonatal care.

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

Importance

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

Objective

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

Methods

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

Results

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

Interpretation

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

Association of a Zero-Separation Neonatal Care Model With Stress in Mothers of Preterm Infants

IMPORTANCE

Active participation in care by parents and zero separation between parents and their newborns is highly recommended during infant hospitalization in the neonatal intensive care unit (NICU).

OBJECTIVE

To study the association of a family integrated care (FICare) model with maternal mental health at hospital discharge of their preterm newborn compared with standard neonatal care (SNC).

DESIGN, SETTING, AND PARTICIPANTS

This prospective, multicenter cohort study included mothers with infants born preterm treated in level-2 neonatal units in the Netherlands (1 unit with single family rooms [the FICare model] and 2 control sites with standard care in open bay units) between May 2017 and January 2020 as part of the AMICA study (fAMily Integrated CAre in the neonatal ward). Participants included mothers of preterm newborns admitted to participating units. Data analysis was performed from January to April 2021.

EXPOSURES

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

Maternal mental health, measured using the Parental Stress Scale: NICU (PSS-NICU). Secondary outcomes included survey scores on the Hospital Anxiety and Depression Scale, Postpartum Bonding Questionnaire, Perceived Maternal Parenting Self-efficacy Scale, and satisfaction with care (using EMPATHIC-N). Parent participation (using the CO-PARTNER tool) was assessed as a potential mediator of the association of the FICare model on outcomes with mediation analyses.

RESULTS

A total of 296 mothers were included; 124 of 141 mothers (87.9%) in the FICare model and 115 of 155 (74.2%) mothers in SNC responded to questionnaires (mean [SD] age: FICare, 33.3 [4.0] years; SNC, 33.3 [4.1] years). Mothers in the FICare model had lower total PSS-NICU stress scores at discharge (adjusted mean difference, -12.24; 95% CI, -18.44 to -6.04) than mothers in SNC, and specifically had lower scores for mother-newborn separation (adjusted mean difference, -1.273; 95% CI, -1.835 to -0.712). Mothers in the FICare model were present more (>8 hours per day: 105 of 125 [84.0%] mothers vs 42 of 115 [36.5%]; adjusted odds ratio, 19.35; 95% CI, 8.13 to 46.08) and participated more in neonatal care (mean [SD] score: 46.7 [6.9] vs 40.8 [6.7]; adjusted mean difference, 5.618; 95% CI, 3.705 to 7.532). Active parent participation was a significant mediator of the association between the FICare model and less maternal depression and anxiety (adjusted indirect effect, -0.133; 95% CI, -0.226 to -0.055), higher maternal self-efficacy (adjusted indirect effect, 1.855; 95% CI, 0.693 to 3.348), and better mother-newborn bonding (adjusted indirect effect, -0.169; 95% CI, -0.292 to -0.068).

CONCLUSIONS AND RELEVANCE

The FICare model in our study was associated with less maternal stress at discharge; mothers were more present and participated more in the care for their newborn than in SNC, which was associated with improved maternal mental health outcomes. Future intervention strategies should aim at reducing mother-newborn separation and intensifying active parent participation in neonatal care.

TRIAL REGISTRATION

Netherlands Trial Register identifier NL6175.

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.