Table 2.

Themes and supporting quotations

Theme description	Example quote
Context
Numerous stressors experienced by NICU families are magnified in a safety-net environment	Quote 1A: “It’s definitely beneficial, especially because I feel like our population has a lot of needs that not necessarily other hospitals do. Many of our families have low incomes and many needs…I think everyone sees that our families need more than we’ve been able to provide for them, and this is a path to get us there.”(participant 12) Quote 1B: “NICU families have so many obstacles to come up against between getting here, daycare, other kids at home, work, etc. Honestly, I don’t know how they do it. And then trying to deal with the trauma of having a baby in the NICU. These families are so resilient, they deserve that we do better by them, that we do anything we can do to help them. I mean, it’s just so much going on. I mean, you visit somebody in the hospital…After a week you’re like ‘I can’t take this anymore.’ And here, they’re visiting their babies for months and months. If we can use this opportunity to identify needs and give them resources, I think it’s a great step forward.” (participant 20)
Nurses had varying viewpoints of the roles and responsibilities for social care in the NICU	Quote 2A: “Some nurses may feel like ‘why do I have to do this on top of everything else I have to do?’ Or ‘this isn’t really our job.’ That’s why the NICU has social workers you know. Even when they are positive about the program. It’s just like who should really institute things and whose responsibility is it to do this.”(participant 13) Quote 2B: “I mean, it’s part of our job. I mean, it’s – I think it’s important. I think it’s important for the parents. I don’t think it’s that difficult or too much to ask I guess …of us to do. I feel like it kind of flows into just conversation, teaching, just basic sharing with the parents that we already do. Like if we’re in and out of the room all day, and if the parent is staying the whole day then you kind of build more of a relationship with them and you talk about these things. Not to say that doctors don’t, it’s just I think the way our workflow works versus theirs.”(participant 16) Quote 2C: “I would say sometimes it’s hard for social work to do everything. For example, we get a lot of patients with so many social needs, so it’s hard for social work to provide absolutely everything for every patient. So, it just kind of gives us the opportunity to help them [families] more. It kind of gives the nurses an insight into the specifics of that a family might need. It gives us almost permission to ask some of those questions that sometimes have been reserved for social work.”(participant 4)
Scarcity of community resources makes it difficult to address families’ needs	Quote 3A: “I know from experience that community agencies are overwhelmed. There’s too many people in need of help, and few resources to help them.”(participant 25) Quote 3B: “I am worried that community agencies won’t be able to help our families as much as we hope they will. There is so much bureaucracy in some of these agencies. And sometimes they are just not able to meet the needs of families, housing is a big one.”(participant 9)
Evidence
The intervention enabled greater identification of unmet social needs and increased provision of resources	Quote 4A: “These are things that have been going on here for many, many years. It’s nice to identify these things and have other supports to give. I think families often have questions about resources but they not always ask. With THRIVE [the intervention], it’s just more available to them. We have an easy tool to provide them with when they ask for resources. Or if they’re uncomfortable asking it’s a way to get them to disclose the help they need –without them having to ask first.”(participant 18) Quote 4B: “We have one parent that sticks out in my mind. The mother was Spanish speaking and before she was screened, we didn’t know there were any issues even though she had already met with the social worker. Well, come to find out the mother was staying here every single night because the dad lost his job and they didn’t have money for food. So she was staying here for food. After the THRIVE screen was done by one of our nurses who speaks Spanish, we found all of this out and they got her connected to the pantry that same day. That mom returned from the pantry with big smiles on her face, and just felt such a relief.”(participant 8) Quote 4C: “I actually attended one of the meetings where an agency was presenting and learned about what they can offer, which is terrific. I’m not sure that we even were aware at how many community assists and supports there were available to our parents.”(participant 20) Quote 4D: “I appreciate the immediacy of it, especially for the Uber Health to be able to access rides, and discounted parking and also foodbank, that’s huge. I can’t believe I didn’t know about the BMC foodbank before, that we can provide access to that. It just eliminates a lot of the what ifs, especially for families who may be new to the area or new to the country.”(participant 11)
The intervention has the potential to jumpstart better caregiver and infant health and well-being trajectories	Quote 5A: “The baby has to go home to a safe place with food and heat and there’s a lot of stress for the families, and I think that if this program can identify needs earlier on, it can probably help a lot of these issues, as simple as transportation to come see their baby, I think it makes the bonding and just kind of being a parent more in the focus, and it makes the stress less on the parents, which in the end helps the baby.”(participant 4) Quote 5B: “The earlier that we start it, the earlier that we can actually set them [families] up with resources, the better for the baby to go home. So, to have everything set up or at least started before baby is discharged is important. So, it’s kind of like a jumpstart.”(participant 2) Quote 5C: “I like it because we can begin to address social determinants of health, and get people better care, and get families out of the cycle of poverty. You need a job to get good food and healthy food for your family. THRIVE [the intervention] touches upon things that like we wouldn’t normally. Like if the baby is going to be here for a really long time, say one of the parents is interested in resources for education like one family I had, or someone in the house is looking for work or anything like that, that can help them get on their feet and have better opportunities.”(participant 10)
Facilitation
Dynamic training and champion support increased nurses’ comfort with the intervention	Quote 6A: “We went over what the program was. We went over the screening tool, the questions that we were going to ask. We created some scripts that I thought were helpful. For example, how to introduce yourself, how to explain the THRIVE program [the intervention], and to make it so that it was actually something that was helpful and useful versus intimidating. I really liked the role play for example with a pretend parent who was suspicious of why we were asking these questions. So we did it only after feeling comfortable with it. And then after that, after learning all the questions, then we also learned about the various resources that were available and how to connect the families with those resources.” (participant 11) Quote 6B: “There were a couple of videos we watched, and then [redacted name] came around and she did it with us individually, and we would role play for a little bit with each other, and then we practiced with each other before doing it with patients. And now there’s always somebody here that if you don’t know how to do something there’s support.”(participant 15)
Regular feedback to nurses on intervention outcomes improved buy-in	Quote 7A: “I really liked it when they shared with us the data on what happened with the referrals. I loved to learn that many families had used the resources or had enrolled in the programs we offered them. We don’t want to screen for the sake of screening. One of the mothers shared her experience with the English program and she was so excited about it, it was great to hear. I’d love to see the data on the feedback coming in from families that I know they are getting, that’ll kind of tell us what we need to do, how to steer the ship.”(participant 6) Quote 7B: “We did change some resources as we found out that some of the resources, they were not as helpful for our parents or some other resources were more advanced. So, we learned and changed things, we fine-tuned our resources as we found other places that offered more or better services. I really liked that.”(participant 3)
Procedures to reduce bias and stigma increased acceptability of the intervention	Quote 8A: “It provides, I hope, a little more intimacy and trust with the parents once they know we’re on their side, and this isn’t about outing them, or letting authorities know that they’re here. We have to acknowledge their lived experiences and the many reasons they have distrust the system. I mean, I always want parents to feel comfortable with us, and the way we present THRIVE [the intervention] is a great way to provide them with, again, a sense of trust, and some community options that they may not be aware of.”(participant 7) Quote 8B: “You want to develop a relationship with the patient before you sit down and kind of ask those questions, or for them to trust you with their honest responses. So, it is definitely best for either like a primary nurse or somebody who has taken care of the baby at least a few times to ask the questions. I personally believe that matters to families.”(participant 2) Quote 8C: “Considering everybody is asked it, it kind of sets a precedent of, okay, they’re not just asking me because they think I need it, versus you let them [families] know upfront it is just done for everyone and why we do it. I think that’s important. It’s a nice way to get information without being perceived as biased.”(participant 19)