Implementation of Family Centered Care for Neonates Admitted in a Special Care Baby Unit in Sierra Leone

Purpose

To assess the feasibility of implementing family centered care and the impact this would have on parental satisfaction in a special care baby unit in Sierra Leone.

Patients and Methods

A cross-sectional, mixed methods study was conducted at the Rokupa Government Hospital, Sierra Leone. 16 nursing staff of the Special Care Baby Unit and 7 caregivers of neonates admitted in the unit participated in the study. Quantitative data on feasibility was obtained from nursing staff using a five-point Likert scale administered to staff before and after implementation of family centered care in the unit. Qualitative data on perception of impact was obtained through focus group discussions for caregivers whose neonates had received family centered care and a control group who had received standard unit care. Quantitative data was analyzed using univariate analysis and thematic analysis was undertaken for qualitative data.

Results

Before implementation, most nursing staff felt implementation of family centred care was not feasible (87.5%) and more than half of nursing staff either strongly agreed or agreed with each of the negative statements regarding the practice of family centred care indicating a generally negative perception. After implementation there was improvement in nursing staff perception of family centred care, however the majority still doubted the continued feasibility of this practice (68.8%). Qualitative discussions with caregivers demonstrated that caregivers whose babies received family centered care were less distressed and more satisfied during the period of admission than those who received routine care.

Conclusion

Family centered care improved the experiences of caregivers in the unit. Nursing staff also demonstrated a better understanding of the benefits of family centered care after it was implemented. Concerns regarding understaffing and the unit being too small to accommodate caregivers and staff at the same time need to be addressed. There is need to integrate family centered care into hospital policy.

Families' perception of proposed nutrition screening on admission to pediatric hospitals: a qualitative analysis

Nutrition screening is the first step in most acute care pediatric nutrition care pathways. However, there is a lack of understanding of patient and families' perception of nutrition screening in pediatric populations. The objective of this study was to explore the potential perceptions, feelings, and opinions of families if pediatric nutrition screening were to be completed during hospital admission. Nine members of the Family Advisory Council at the Alberta Children's Hospital participated in a focus group to discuss questions around nutrition screening practices, malnutrition, and the pediatric nutrition screening tool. Transcripts were analyzed using MAXQDA and thematic analysis using the Braun and Clarke methodology. Two major themes emerged: screening may raise sensitive emotions and understanding the purpose of nutrition screening and the questions. Participants agreed discussions around growth and nutrition are vital to comprehensive medical care; however, the timing and approach of nutrition screening can lead to anxiety and feelings of judgement. A lack of understanding of the purpose of screening, next steps, and benefit to the individual patient could limit acceptance of nutrition screening. The findings of this study can inform training and education of healthcare professionals involved in nutrition screening.

Parent Perspectives: Part 2-Considerations for the Transition Home Post-NICU Discharge

This paper is part two of a series of papers written by the mothers of Neonatal Intensive Care Unit (NICU) graduates. The companion paper, "Parent Perspectives: Part 1-Considerations for Changing the NICU Culture", considers all aspects of the NICU experience and provides recommendations for interventions and improvements from a life-course perspective while families are in the NICU. In part two, the focus is the transition home post-NICU stay. The time after NICU discharge is a critical and sensitive developmental period for NICU babies and their families, and an important life course transition. This paper provides a parent's perspective of how to improve the transition home post-NICU stay. Our perspectives draw on the Life Course Health Development approach, which regards health as an active process that is developed over time based on a person's internal biologic and physiologic systems, their external environment and circumstances, and the interactions or relationships between them. This paper describes a collaborative care model where parents and their healthcare teams work together to develop shared care plans. It also describes how we can build trust and family capacity to support long-term care, ensure family well-being, and link families to needed resources and support that can ease the transition from the NICU back to the home and optimize family health trajectories.

The Development of a Communication Tool to Aid Parent-Centered Communication between Parents and Healthcare Professionals: A Quality Improvement Project

Good communication is central to good healthcare. As a result of poor communication between parents and healthcare professionals (HCPs) in clinical settings, this study aimed to address this problem by developing a communication tool to empower parents and act as a prompt for HCPs to talk about the child's care and gather information at the point of admission to hospital about what is important to families, therefore supporting patient-centered communication. A design thinking process was used to develop a physical copy of Chloe's card and evaluate its use. Design thinking is a problem-solving approach, which uses an empathetic lens to integrate viewpoints of different stakeholders throughout the process of creating solutions. Design thinking involves five processes: (1) empathise-including a literature review and data synthesis, (2) define-by completing semi-structured interviews with parents about their experience of communication and HCPs perceptions of parent's experience of communication, (3) ideate-iterate the design of Chloe's card with parents and HCPs, (4) prototype-develop the design of Chloe's card, and (5) test-pilot test in clinical practice. Results from this initial study suggest that a small hand-held card, with emoticons and a place to write concerns, was acceptable to parents and feasible to use in clinical practice. Parents do not always feel heard by HCPs and a tool such as Chloe's card may help facilitate sharing of information about matters important to them and their child. However, some HCPs felt the need for a communication tool undermined their clinical skills. Feedback from HCP participants suggests that the idea of Chloe's card was acceptable and perceived as potentially being useful in clinical practice. Further work is required, as part of a larger study, to further refine this communication tool, identify those parents who would benefit most from Chloe's card, as well as to further refine the HCP process prior to implementing it into clinical settings. It was noted future iterations would benefit from a digital version linked with a child's electronic record, as well as multi-language versions and information for parents.

Humanizing the Intensive Care Unit: Perspectives of Patients and Families on the Get to Know Me Board

In this qualitative study, we explored perspectives of patients in the intensive care unit (ICU) and their families on the Get to Know Me board (GTKMB). Of the 46 patients approached, 38 consented to participate. Of the 66 family members approached, 60 consented to participate. Most patients (26, 89%) and family members (52, 99%) expressed that GTKMB was important in recognizing patient's humanity. Most patients (20, 68%) and families (39, 74%) said that it helped to build a better relationship with the provider team. 60% of patients and families commented that the GTKMB was used as a platform by providers to interact with them. Up to 45 (85%) of the family members supported specific contents of the GTKMB. In structured interviews (11 patients, 7 family members), participants additionally commented on ways providers used the GTKMB to communicate, support patient's personhood, and on caveats in interacting with GTKMB. Critically ill patients and families found the GTKMB helpful in preserving personhood of patient, fostering communication, and building relationships with clinicians.

A Proxy Approach to Family Involvement and Neurocognitive Function in First Episode of Non-Affective Psychosis: Sex-Related Differences

Schizophrenia spectrum disorders (SSD) often show cognitive deficits (CD) impacting daily life. Family support has been shown to be protective against CD, yet the relationship between these in psychotic patients remains complex and not fully understood. This study investigated the association between a subdomain of family support, namely, family involvement (estimated through a proxy measure), cognitive functioning, and sex in first-episode psychosis (FEP) patients. The sample included 308 patients enrolled in the Program for Early Phases of Psychosis (PAFIP), divided into 4 groups based on their estimated family involvement (eFI) level and sex, and compared on various variables. Women presented lower rates of eFI than men (37.1% and 48.8%). Higher eFI was associated with better cognitive functioning, particularly in verbal memory. This association was stronger in women. The findings suggest that eFI may be an important factor in FEP patients' cognitive functioning. This highlights the importance of including families in treatment plans for psychotic patients to prevent CD. Further research is needed to better understand the complex interplay between family support, sex, and cognitive functioning in psychotic patients and develop effective interventions that target these factors.

Design and Integration of a Texting Tool to Keep Patients' Family Members Updated During Hospitalization: Clinicians' Perspectives

An important gap in the literature is how clinicians feel about patient-centered technologies and how clinicians experience patient-centered technologies in their workflows. Our goal was to identify clinician users' perspectives on facilitators (pros) and barriers (cons) to using 1 digital texting innovation to promote family centered care during patients' hospitalizations. This qualitative study was conducted at a tertiary care center in Houston, consisting of 7 hospitals (1 academic hospital and 6 community hospitals), involving analyzation of 3 focus groups of 18 physicians, 5 advanced practice providers, and 10 nurse directors and managers, as well as a content analysis of 156 real-time alerts signaling family dissatisfaction on the nursing unit/floor. Thematic analysis methods were used. We selected these participants by attending their regularly scheduled service-line meetings. Clinician feedback from focus groups resulted in 3 themes as facilitators: (a) texting platforms must be integrated within the electronic medical record; (b) texting reduces outgoing phone calls; (c) texting reduces incoming family phone calls. Clinician feedback resulted in 3 themes as barriers: (a) best practice alerts can be disruptive; (b) real-time alerts can create hopelessness; and (c) scale-up is challenging. The analyzation of facilitators (pros) and barriers (cons) pertains only to the clinician's feedback. We also analyzed real-time alerts signaling family dissatisfaction (defined as "service recovery escalation" throughout this manuscript). The most common selection for the source of family dissatisfaction, as reflected through the real-time alerts was, "I haven't heard from physicians enough," appearing in 52 out of 156 alerts (33%). The second most common selection for the source of dissatisfaction was "perceived inconsistent or incomplete information provided by team members," which was selected in 48 cases (31%). Our findings indicate that clinicians value inpatient texting, not only for its ability to quickly relay updates to multiple family members with 1 click, but also because, when used intentionally and meaningfully, texting decreases family phone calls.

Barriers and enablers of breastfeeding in mother-newborn dyads in institutional settings during the COVID-19 pandemic: A qualitative study across seven government hospitals of Delhi, India

Introduction

The COVID-19 pandemic disrupted newborn care and breastfeeding practices across most healthcare facilities. We undertook this study to explore the barriers and enablers for newborn care and breastfeeding practices in hospitals in Delhi, India for recently delivered mother (RDM)-newborn dyads during the first wave of the COVID-19 pandemic (2020) and inductively design a "pathway of impaction" for informing mitigatory initiatives during the current and future pandemics, at least in the initial months.

Materials and methods

We used an exploratory descriptive design (qualitative research method) and collected information from seven leading public health facilities in Delhi, India. We conducted separate interviews with the head and senior faculty from the Departments of Pediatrics/Neonatology (n = 12) and Obstetrics (n = 7), resident doctors (n = 14), nurses (labor room/maternity ward; n = 13), and RDMs (n = 45) across three profiles: (a) COVID-19-negative RDM with healthy newborn (n = 18), (b) COVID-19-positive RDM with healthy newborn (n = 19), and (c) COVID-19 positive RDM with sick newborn needing intensive care (n = 8) along with their care-giving family members (n = 39). We analyzed the data using grounded theory as the method and phenomenology as the philosophy of our research.

Results

Anxiety among clients and providers, evolving evidence and advisories, separation of the COVID-positive RDM from her newborn at birth, providers' tendency to minimize contact duration and frequency with COVID-positive mothers, compromised counseling on breastfeeding, logistic difficulties in expression and transportation of COVID-positive mother's milk to her baby in the nursery, COVID restrictions, staff shortage and unavailable family support in wards and nursery, and inadequate infrastructure were identified as major barriers. Keeping the RDM-newborn together, harmonization of standard operating procedures between professional associations and within and between departments, strategic mobilization of resources, optimization of human resources, strengthening client-provider interaction, risk triaging, leveraging technology, and leadership-in-crisis-situations were notable enablers.

Conclusion

The separation of the RDM and newborn led to a cascade of disruptions to newborn care and breastfeeding practices in the study institutions. Separating the newborn from the mother should be avoided during public health emergencies unless there is robust evidence favoring the same; routine institutional practices should be family centered.

Patient Satisfaction With Primary Healthcare Services in Al-Ahsa, Saudi Arabia

Background Patient satisfaction is regarded as a valid and significant indicator of the quality of medical care delivered. Additionally, it has been shown to be linked to better health outcomes. The goal of the study is to assess patients' overall satisfaction regarding primary healthcare (PHC) services. Methodology In this cross‑sectional study conducted in Al-Ahsa, we used the General Practice Assessment Questionnaire and its four subscales with standard cutoffs. A sample of 287 patients was conveniently selected from PHC centers. Results A total of 287 patients were included. Patients' ages ranged from 18 to more than 65 years with a mean age of 32.5 ± 13.9 years old. In total, 177 (61.7%) patients were female, and 225 (78.4%) reviewed the physician for their own problems. A total of 95 (33.1%) patients had chronic health problems. Overall, of the study patients, a total of 38 (13.2%) were highly satisfied regarding provided services, while 45 (15.7%) had a low overall satisfaction level. In general, the mean score (%) of patient satisfaction was 61.9 ± 11.8. Conclusions The level of satisfaction with the services provided by PHC centers in Al-Ahsa is moderate. The level of satisfaction concerning some services provided by PHC centers differs significantly according to age, gender, presence of chronic health problems, and employment status.

Staff Perceptions of Family-Centered Care in Italian Neonatal Intensive Care Units: A Multicenter Cross-Sectional Study

Family Centered Care (FCC) in Neonatal Intensive Care Units (NICUs) included family involvement in the care process of newborns and infants. Staff perceptions of FCC may influence clinical practice and management strategies in NICUs, with an impact on quality and humanization of the care. The Family-Centred Care Questionnaire-Revised (FCCQ-R) was adapted for the NICU setting, therefore the FCCQ-R@it-NICU was developed and used for the present study in 32 Italian NICUs. We calculated internal consistency using Cronbach’s alpha correlation between Current and Necessary dimensions of the scale using the Pearson correlation coefficient. Furthermore, we investigated which characteristics could influence staff perceptions of FCC in NICUs. 921 NICU professionals participated in the study. The FCCQ-R@it-NICU revealed good internal consistency (0.96) and good correlation between dimensions (p < 0.05). Statistical and significant differences in Current and Necessary dimensions were found and some demographic characteristics were found predictable on FCC practice. The FCCQ-R@it-NICU is a valid tool to investigate staff perceptions about FCC in NICU settings. Profession, education level and work experience seem to positively influence the perception of what is required for FCC practice within NICUs.

Israeli Parents' Lived Experiences of Music Therapy With Their Preterm Infants Post-Hospitalization

In the current study, we aimed to explore the lived experience of Israeli parents who engaged in musical dialogues with their preterm infants during music therapy (MT) after being discharged from the neonatal intensive care unit (NICU), as a part of the multinational LongSTEP RCT. Seven participants of the main trial were invited to engage in semi-structured in-depth interviews intertwining listening to audio recordings from their music therapy sessions in an adapted interpersonal process recall (IPR) procedure. The interviews were transcribed and analyzed using interpretative phenomenological analysis (IPA). We understood the participants' experiences to reflect two main themes: 1) Music therapy as a potential means of transformation in communication skills, resourcefulness and sense of agency; and 2) emotional and musical preconditions for parental engagement in MT. The findings illustrate how a specific group of Israeli parents experienced MT as offering them a means of expanding their relationship with their preterm infants after discharge. Based on our findings, we recommend that music therapists consider parents' musical and emotional resources during post-discharge MT to meet the individual needs of families.

Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

BACKGROUND AND SIGNIFICANCE

Advances in pediatric intensive care have led to markedly improved survival rates in critically ill children. Approximately 70% of those children survive with varying forms of complex chronic diseases or impairment/disabilities. Length of stay, length of mechanical ventilation and number of interventions per patient are increasing with rising complexity of underlying diseases, leading to increasing pain, agitation, withdrawal symptoms, delirium, immobility, and sleep disruption. The ICU-Liberation Collaborative of the Society of Critical Care Medicine has developed a number of preventative measures for prevention, early detection, or treatment of physical and psychiatric/psychological sequelae of oftentimes traumatic intensive care medicine. These so called ABCDEF-Bundles consist of elements for (A) assessment, prevention and management of pain, (B) spontaneous awakening and breathing trials (SAT/SBT), (C) choice of analgesia and sedation, (D) assessment, prevention and management of delirium, (E) early mobility and exercise and (F) family engagement and empowerment. For adult patients in critical care medicine, research shows significant effects of bundle-implementation on survival, mechanical ventilation, coma, delirium and post-ICU discharge disposition. Research regarding PICS in children and possible preventative or therapeutic intervention is insufficient as yet. This narrative review provides available information for modification and further research on the ABCDEF-Bundles for use in critically ill children.

MATERIAL AND METHODS

A narrative review of existing literature was used.

RESULTS

One obvious distinction to adult patients is the wide range of different developmental stages of children and the even closer relationship between patient and family. Evidence for pediatric ABCDEF-Bundles is insufficient and input can only be collected from literature regarding different subsections and topics.

CONCLUSION

In addition to efforts to improve analgesia, sedation and weaning protocols with the aim of prevention, early detection and effective treatment of withdrawal symptoms or delirium, efforts are focused on adjusting ABCDEF bundle for the entire pediatric age group and on strengthening families' decision-making power, understanding parents as a resource for their child and involving them early in the care of their children.

Mothers and nurses' perceptions of the family-centered care barriers in pediatric departments of an educational hospital in Iran

PROBLEM

Family-centered care (FCC) is a concept used to describe an approach to caring for children and their families within health services. This study compared mothers and nurses' perceptions of barriers to FCC.

METHODS

This cross-sectional study was conducted in an educational hospital affiliated to Kerman University of Medical Sciences at the southeast of Iran in 2019. Using a researcher-designed questionnaire, we assessed mothers' and nurses' perceptions of barriers to FCC with a census method (60 nurses and 82 mothers).

FINDINGS

Mothers (49.8 ± 21.1) and nurses' (49.2 ± 16.4) mean scores of the perception of FCC barriers were at a moderate level. No significant difference was found between mothers' and nurses' perceptions of barriers to FCC. A significant relationship was observed between age, child's admission history, and the perception of FCC barriers in the mothers' group.

CONCLUSION

Findings suggest that national and regional policies of educational hospitals should assess factors contributing to the FCC barriers, focus on how to reduce these barriers, and provide appropriate collaborative care by nurses and the family of patients.

A Pilot Study of a Measure of Parental Trust in Pediatric Emergency Department Care Teams

OBJECTIVE

To modify and test an existing measure of trust validated in a primary care setting for use in a pediatric emergency department (PED).

METHODS

The study population was parents/guardians who brought their child to an urban PED with a chief complaint of abdominal pain or head injury. We used a 2-phase design with modifications resulting from cognitive interviews with 15 participants followed by a field test with 150 participants. We measured usefulness by percent missing responses and ceiling effects. Cronbach's alpha and greatest lower bound measured reliability. As evidence of validity, we calculated a total trust score by summing the item scale values and correlating the score with measures of constructs shown to be positively associated with trust in other settings. We conducted a similar analysis to test a published shortened version of the same scale.

RESULTS

Four items were modified prior to field testing. Ceiling effects for each item ranged from 53% to 67%. Missing data were minimal affecting only 2 items. The modified measure exhibited high reliability (Cronbach's alpha = .88, greatest lower bound = 0.93). Total trust scores ranged from 27 to 50 with mean (standard deviation) = 45.1 (4.9). The trust score exhibited a high positive correlation with communication and overall satisfaction, and moderate correlation with intent to adhere to physician recommendations. The short version of the scale performed similarly.

CONCLUSIONS

This study provides evidence that the modified Wake Forest measure of trust is applicable and useful in the PED setting for this patient population.

Changes of Infant- and Family-Centered Care Practices Administered to Extremely Preterm Infants During Implementation of the NIDCAP Program

Introduction: Many studies have evaluated the Neonatal Individualized Developmental Care and Assessment Program (NIDCAP), but few studies have assessed changes in infant- and family-centered developmental care (IFCDC) practices during its implementation. Objectives: The primary objective of this single center study was to investigate the impact of the implementation of the NIDCAP program on IFCDC practices used for management of extremely preterm infants (EPIs). The secondary objective was to determine during implementation the impact of this program on the short-term medical outcomes of all EPIs hospitalized at our center. Methods: All EPIs (<28 weeks gestational age) who were hospitalized at Strasbourg University Hospital from 2007 to 2014 were initially included. Outborn infants were excluded. The data of EPIs were compared for three time periods: 2007 to 2008 (pre-NIDCAP), 2010 to 2011, and 2013 to 2014 (during-NIDCAP implementation) using appropriate statistical tests. The clinical and caring procedures used during the first 14 days of life were analyzed, with a focus on components of individualized developmental care (NIDCAP observations), infant pain management (number of painful procedures, clinical pain assessment), skin-to-skin contact (SSC; frequency, day of initiation, and duration), and family access and involvement in the care of their children (duration of parental presence, parental participation in care). The short-term mortality and morbidity at discharge were evaluated. Results: We examined 228 EPIs who received care during the three time periods. Over time, painful procedures decreased, but pain evaluations, parental involvement in care, individualized observations, and SSC increased (all p < 0.01). In addition, the first SSC was performed earlier (p = 0.03) and lasted longer (p < 0.01). There were no differences in mortality and morbidity, but there were reductions in the duration of mechanical ventilation (p = 0.02) and the time from birth to first extubation (p = 0.02), and an increase of weight gain at discharge (p = 0.02). Conclusion: NIDCAP implementation was accompanied by progressive, measurable, and significant changes in IFCDC strategies. There were, concomitantly, moderate but statistically significant improvements in multiple important outcome measures of all hospitalized EPI.

Parents' Reported Experiences When Having a Child with Cataract-Important Aspects of Self-Management Obtained from the Paediatric Cataract Register (PECARE)

Parents are a crucial part in the care of children with pediatric cataract. The aim of this study was to explore and explain sense of coherence, family self-efficacy, perceived social support, fatigue and parent reported experiences (PREM), in order to improve clinical care. Questionnaires were sent to the parents of children registered in the Swedish national Pediatric Cataract Register, PECARE, from 2006–2019 (n = 506). The response rate was 46% (n = 231), 185 mothers and 44 fathers with a mean age of 40.39 years (SD ± 6.41 years). In total, 38% of the parents reported severe fatigue, and mothers were more burdened than fathers. Sense of coherence was strongly related to fatigue, especially among parents of children with bilateral cataract. Mental fatigue and reduced motivation explained 45% of the variation in sense of coherence. Being taken seriously by the ophthalmological clinic explained over 60% of the variation in satisfaction with care when controlled for parents’ age and gender. In conclusion, fatigue is important to take in consideration when interacting with parents of children with cataract, especially those with bilateral cataract. Being taken seriously is the key marker of satisfaction with care and support from professionals. In addition to fatigue, the parents’ age and life situation affect how they perceive their own, as well as the professionals’ effort, and should be considered when tailoring family-centered care.

Supporting families on their journey towards a normal everyday life - facilitating partnership in an early discharge program for families with premature infants

PURPOSE

Several Danish neonatal intensive care units (NICUs) offer the possibility of an early discharge program (EDP) for families with premature infants, when the infant reaches the gestational age ≥ 34 weeks and a weight ≥ 1,500 g. The purpose of this study is to explore how the partnership with these families can be facilitated by the nurse based on the principles of the framework of family centered care (FCC).

DESIGN AND METHODS

The study was conducted as an ethnographic inquiry inspired by Spradley and based on participant observation of 12 contacts between nurse and family, one informal and three formal interviews with nurses in the EDP-unit of a Danish NICU.

RESULTS

This study illustrates how EDP-nurses facilitate a partnership with the families enrolled in EDP by using a range of complex strategies to adjust their care to the family's changing needs, while acknowledging the family's way of being. The partnership typically develops in three phases: "Settling in EDP," "Thriving in EDP," and "Leaving the EDP nest." The EDP-nurses have a clear understanding of whether a partnership is well functioning or challenging and they play a unique role by facilitating a partnership that supports the family on the journey towards a normal everyday life.

PRACTICE IMPLICATIONS

The knowledge unraveled in this study may prove helpful for training future EDP-nurses in the neonatal field of FCC, when improving the quality of an existing EDP or developing a new EDP based on the principles of FCC.

Integration of Maternity and Neonatal Care to Empower Parents

OBJECTIVE

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

DESIGN

A descriptive, qualitative analysis.

SETTING

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

PARTICIPANTS

Six staff members who were involved in the transition.

METHODS

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

RESULTS

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

CONCLUSION

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

Caring for Children with Non-Accidental Head Injuries: A Case for a Child-Centered Approach

Child abuse remains a significant issue. Non-accidental head injury (NAHI) is a major cause of mortality in young children with survivors often having to live a life with severe developmental and neurological dysfunction. The aim of this hermeneutic phenomenological research study was to examine the lived experiences of nurses who care for children and their families admitted to hospital with a non-accidental head injury. Semi-structured interviews were conducted with six nurses who had at least five years' experience of nursing children with NAHI. Following the interpretive approach described by van Manen data was analyzed and two essential themes identified. Firstly, nursing children with NAHI is different from the care of children admitted with a similar neurological injury related to accidental injuries or medical conditions. Secondly, when nursing these children nurses adopt protective qualities, conceptualized in this study as a shield of protection. The findings of this study support the findings of other studies in regard to the emotional labor required of nurses caring for children who have been subject to child abuse and the importance for nurses of maintaining a professional demeanor. The study highlighted the tensions of sustaining a family-centered care approach when caring for a child with NAHI. It is argued that greater acknowledgment and emotional support for nurses is needed and that a child-centered approach offers a more compatible model of care than Family-Centered Care in the acute phase of caring for children with a NAHI.

Canadian Hospital and Home Visiting Nurses' Attitudes Toward Families in Transitional Care: A Descriptive Comparative Study

Despite the key role that hospital and home care nurses have in supporting family carers in transitional care, there is limited comparative information on their attitudes toward supporting family carers during care transitions. As part of a larger research project, we conducted a descriptive comparative study using a cross-sectional survey. Canadian nurses (105 hospital, 34 home visiting) completed a demographic questionnaire and the Families' Importance in Nursing Care-Nurses' Attitudes (FINC-NA) measurement tool. There were no statistically significant differences between hospital and home visiting nurses' attitudes, which were positive about including families in care. Nurses who reported having a workplace philosophy or general approach to the care of family held more positive attitudes toward families than those who did not. This is important because positive attitudes are often linked to better communication with family carers and thus, better patient and carer outcomes. To our knowledge, only one Canadian master's thesis has used this tool. Thus, this research furthers understanding of nurse attitudes within a Canadian context. Furthermore, this article adds to the literature by including suggestions for future research that are based in social psychological theories. Interdisciplinary knowledge can help pre- and postlicensure clinicians in advanced family nursing to better lever barriers and facilitators within family nursing practice.

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.

Novel, Family-Centered Intervention to Improve Nutrition in Patients Recovering From Critical Illness: A Feasibility Study

BACKGROUND

Critically ill patients are at increased risk of developing malnutrition-related complications because of physiological changes, suboptimal delivery, and reduced intake. Strategies to improve nutrition during critical illness recovery are required to prevent iatrogenic underfeeding and risk of malnutrition. The purpose of this study was to assess the feasibility and acceptability of a novel family-centered intervention to improve nutrition in critically ill patients.

MATERIALS AND METHODS

A 3-phase, prospective cohort feasibility study was conducted in 4 intensive care units (ICUs) across 2 countries. Intervention feasibility was determined by patient eligibility, recruitment, and retention rates. The acceptability of the intervention was assessed by participant perspectives collected through surveys. Participants included family members of the critically ill patients and ICU and ward healthcare professionals (HCPs).

RESULTS

A total of 75 patients and family members, as well as 56 HCPs, were enrolled. The consent rate was 66.4%, and 63 of 75 (84%) of family participants completed the study. Most family members (53/55; 98.1%) would recommend the nutrition education program to others and reported improved ability to ask questions about nutrition (16/20; 80.0%). Family members viewed nutrition care more positively in the ICU. HCPs agreed that families should partner with HCPs to achieve optimal nutrition in the ICU and the wards. Health literacy was identified as a potential barrier to family participation.

CONCLUSION

The intervention was feasible and acceptable to families of critically ill patients and HCPs. Further research to evaluate intervention impact on nutrition intake and patient-centered outcomes is required.

Real life clinic visits do not match the ideals of shared decision making

OBJECTIVE

To use observation to understand how decisions about higher-risk treatments, such as biologics, are made in pediatric chronic conditions.

METHODS

Gastroenterology and rheumatology providers who prescribe biologics were recruited. Families were recruited when they had an outpatient appointment in which treatment with biologics was likely to be discussed. Consent/assent was obtained to video the visit. Audio of the visits in which a discussion of biologics took place were transcribed and analyzed. Our coding structure was based on prior research, shared decision making (SDM) concepts, and the initial recorded visits. Coded data were analyzed using content analysis and comparison with an existing model of SDM.

RESULTS

We recorded 21 visits that included discussions of biologics. In most visits, providers initiated the decision-making discussion. Detailed information was typically given about the provider's preferred option with less information about other options. There was minimal elicitation of preferences, treatment goals, or prior knowledge. Few parents or patients spontaneously stated their preferences or concerns. An implicit or explicit treatment recommendation was given in nearly all visits, although rarely requested. In approximately one-third of the visits, the treatment decision was never made explicit, yet steps were taken to implement the provider's preferred treatment.

CONCLUSIONS

We observed limited use of SDM, despite previous research indicating that parents wish to collaborate in decision making. To better achieve SDM in chronic conditions, providers and families need to strive for bidirectional sharing of information and an explicit family role in decision making.

Brief approaches to developmental-behavioral promotion in primary care: updates on methods and technology

Well-child visits are a critical opportunity to promote learning and development, encourage positive parenting practices, help children acquire behavioral self-control, enhance the development and well-being of children and their families, identify problems not amenable to brief in-office counseling, and refer for services when needed. This article outlines the communication skills, instructional methods, and resource options that enable clinicians to best assist families. Also covered is how to monitor progress and outcomes. A total of 239 articles and 52 Web sites on parent/patient education were reviewed for this study. Providers require a veritable armamentarium of instructional methods. Skills in nonverbal and verbal communication are needed to elicit the parent/patient agenda, winnow topics to a manageable subset, and create the "teachable moment." Verbal suggestions, with or without standardized spoken instructions, are useful for conveying simple messages. However, for complex issues, such as discipline, it is necessary to use a combination of verbal advice, written information, and "teach-back," aided by role-playing/modeling or multimedia approaches. Selecting the approaches most likely to be effective depends on the topic and family characteristics (eg, parental literacy and language skills, family psychosocial risk and resilience factors, children's developmental-behavioral status). When providers collaborate well (with parents, patients, and other service providers) and select appropriate educational methods, families are better able to act on advice, leading to improvements in children's well-being, health, and developmental-behavioral outcomes. Provided are descriptions of methods, links to parenting resources such as cell phone applications, Web sites (in multiple languages), interactive technology, and parent training courses.

Children with special health care needs: Impact of health care expenditures on family financial burden

We investigated the relationship between health care expenditures for Special Health Care Needs (SHCN) children and family perception of financial burden. Using 2005/2006 National Survey of Children with Special Health Care Needs data, a multivariate logistic regression model was used to estimate the relationship between the SHCN child's health care expenditure and perceived financial burden, while controlling for family and child characteristics. Our analysis suggests that health care expenditures for a SHCN child of $250 and more are associated with family perception of financial burden. In addition, families with lower socioeconomic status also perceived financial burden at lower level of expenditures. Members of the health care team who treat children with SHCN have an important role in understanding and assessing family financial burden as part of the care delivery to the child and the family. Our study reinforces the need to treat the whole family as the unit of care, especially when caring for children with special health care needs.