Integrating neonatal intensive care into a family birth center: Describing the Integrated NICU (I-NIC)

Abstract

Parent-infant separation resulting from admission to a neonatal intensive care unit is often reported as the most challenging and distressing experience for parents. Aiming to mitigate the stress of parent-infant separation, a new neonatal care model was designed to integrate neonatal intensive care with delivery and postpartum care. Yet, little is known about the model and its implementation. Therefore, using a qualitative descriptive design with field observations we describe the characteristics of an integrated-neonatal intensive care (I-NIC) model and examined perceptions of clinical staff (n=8) and parents (n=3). The physical layout of the I-NIC rooms required additional oxygen and suction columns and new signage to specify them as NICU-equipped. Other NICU-related equipment was mobile, thus moved into rooms when necessary. Nurses were cross-trained in labor/delivery, postpartum, neonatal care; however, nurses primarily worked within their specific area of expertise. Clinician and parent perceptions of the model were notably positive, reporting decreased anxiety related to separation, increased ability for chest feeding and skin-to-skin care, and improved interdisciplinary care. Future work is needed to understand implementation of the model in other settings, with specific attention to unit architecture, level of NICU care services, patient census, and staff and patient outcomes.

PRECIS

A novel integrated neonatal intensive care model (I-NIC) demonstrated positive benefits for infants, parents, and clinical staff by integrating specialized neonatal care with peripartum care so there is little to no separation between parents and their infants.

INTRODUCTION

Mothers of infants admitted to the neonatal intensive care unit (NICU) report separation from their infant as the highest source of postpartum stress.^1–5 Further, parent-infant separation negatively impacts neurodevelopmental outcomes of the preterm infant.^6–7 Accordingly, new NICU care models supporting family-centeredness and re-design of NICU spaces have been developed to ameliorate the stress of maternal-infant separation, examples include family-centered care (FCC) models and single-family rooms (SFRs). FCC philosophy has long been endorsed and accepted by leading pediatric professionals as the gold standard for providing neonatal and pediatric care.⁸ For care models using FCC principles, the major focus is supporting parents in their role as primary caregivers to their infants.^9–10 FCC is predicated on the following principles: (a) parents should not be separated from their hospitalized infant; (b) parents and health care providers collaborate in caring for the child; and (c) all caregiving should facilitate parental involvement.¹⁰ The goal of any FCC model is to allow parents to develop the skills necessary to provide confident care to their infants in the hospital and after discharge.¹¹ With increased parental involvement, FCC contributes to decreased parental stress, increased parental confidence, improved neurodevelopmental outcomes, and increased overall quality of care delivered in the NICU.^12–17

Many hospital systems and providers have re-designed the NICU environment to increase parental engagement and support FCC practices by building SFRs. The SFR architectural model provides space where each infant is cared for in an individual room, similar to the architectural design of modern adult ICUs. Until the early 2000s, many existing architectural models for NICUs included open-bays or pod designs where multiple isolettes or infant cribs were placed side-by-side. The physical environment and experience of the NICU directly contributes to the quality of outcomes for both infants and families.^18–22 Thus, the movement away from pod- or open-bay NICUs was intentional to create care environments that support neurodevelopment, individualized care, and parental caregiving.¹⁹ Multiple studies demonstrate the positive impact of these individualized environments,¹⁹ associating SFRs with lower parental stress,²⁰ greater family presence,^21–22 and increased delivery of FCC.^23–26 Accordingly, this architectural change suggests promising outcomes for both infants and caregivers.

Another recent and novel development that combines environmental redesign and FCC practices, aiming to mitigate the stress of maternal-infant separation, is the integrated neonatal intensive care (I-NIC) model. I-NIC began with a re-design of the traditional NICU care space, similar to the re-design of labor and delivery units into all-inclusive care rooms (e.g., labor, delivery, recovery, and postpartum (LDRP)).²⁷ When redesigning the NICU environment for the I-NIC model, FCC principles guided the creation of a unit or rooms where labor, delivery, recovery, postpartum, and neonatal intensive care are provided together in the same room. I-NIC incorporates the qualities of LDRP, FCC, and SFRs to create an environment where infants requiring intensive care remain with their mothers in the same LDRP room for the duration of their hospitalization.²⁸ Thus, the I-NIC care model mitigates maternal-infant separation for infants requiring intensive care. In the I-NIC model of care, the mother may be discharged from medical care after recovery from delivery but may continue to stay with her infant until discharge. Regardless of which patient, mother or infant, is ready to be discharged first, both remain together in the same room for the duration of their hospitalization.²⁸ Accordingly, I-NIC focuses on integrating NICU care with maternal care to ease the burden of maternal-infant separation and thus support effective delivery of FCC.

Despite its ability to increase FCC and improve associated infant outcomes (e.g., skin to skin time, greater weight gain, shorter length of stay),²⁹ minimal information is available describing the I-NIC care model. Accordingly, the purpose of this study was to describe the I-NIC care model. Our specific aims were to: 1) describe the physical layout, staffing patterns, unit practices, and team workflow of the site who developed and implemented the I-NIC model and 2) describe the perceptions of clinicians, unit leadership, and parents regarding care delivery in the I-NIC setting.

METHODS

Design

This study used a qualitative descriptive design and field notes from two investigators collected through naturalistic observation to address the aims. The qualitative descriptive design elicited and thematically analyzed perceptions of clinicians, leadership, and parents about the I-NIC model. While conducting semi-structured interviews on site, the investigative team conducted naturalistic observations to describe the I-NIC model in practice and augment interview data. The study was deemed exempt by the University of Michigan and the study site’s institutional review boards.

Setting

Interviews and naturalistic observation were conducted at a level 2 NICU, which uses the I-NIC model, nested within a regional, community hospital in Iowa. In 2019, the year preceding this study, the hospital had 1,023 live births (1,047 newborns) and 135 admissions to the I-NIC, in which the average infant length of stay was 10.73 days. Of the infants admitted, 12.6% (n = 17) were very preterm (<32 weeks gestational age), 31.9% (n = 43) were late preterm (34–36 weeks gestational age), and 55.5% (n = 75) were term (≥37 weeks gestational age).

Sample

Using purposive and convenience sampling methods, we recruited participants to reflect a broad representation of those familiar with the I-NIC model, including parents, unlicensed assistive personnel (e.g., nursing assistants), registered nurses (birth center and neonatal), nursing leadership, and medical providers. Unit leadership assisted with identifying the types of participants knowledgeable about the I-NIC model, including those on staff during initial implementation and families who experienced both the site’s original NICU model and the I-NIC model. Hospital staff participants met the following eligibility criteria: (a) 18 years of age or older; (b) able to speak and understand English; and (c) designated as staff in the family birth center or I-NIC. Parents (mother and/or father) of infants admitted to the I-NIC unit met the following eligibility criteria: (a) parent of an infant currently receiving care in the I-NIC unit; (b) 18 years of age or older; and (c) able to speak and understand English. After identifying the types of participants and eligibility criteria, we conveniently sampled from the staff and families available during our onsite visit.

Procedures

Aim 1: Description of I-NIC model characteristics

To address Aim 1, two researchers toured the unit, observed normal day-to-day operations for approximately 4 hours, and independently collected and recorded extensive field-notes to describe the unit. Investigators were particularly interested in observing the physical layout of the unit (e.g., patient rooms, staff workstations, and break rooms), composition of care team (e.g., nurse, charge nurse, RTs, providers), unit practices (e.g., rounding, consults, family teaching, care of mom vs. baby), and workflow (e.g., equipment used for communication, charting, communication between team members). Measurements, sketches, and photographs were taken of an empty patient room to describe the physical layout, identifying placement of equipment and beds.

Aim 2: Perceptions of clinical staff working in the I-NICU model

To address Aim 2, we conducted semi-structured interviews with nine participants in a private location on the unit (n= 8) or via telephone (n= 1). Prior to our on-site visit for data collection, unit nursing leadership helped to identify potential participants and provided them with information about the study and the consent form to review. We contacted nursing leadership prior to visiting the I-NIC site to obtain contact information for those who expressed interest and were available during our site visit. We contacted participants ahead of the visit to verify participation, answer questions, and schedule interviews. A semi-structured interview guide (Supplementary Online File 1) was developed for this study and was reviewed and approved by all investigators. All interviews were conducted by two investigators, audio-recorded, and transcribed verbatim. Written consent was obtained from each participant prior to conducting the interview. Interviews lasted approximately 30–45 minutes in length. To append interview data, investigators independently recorded field notes from the interviews. Interviews with clinicians (e.g., nurses and physicians) focused on delivery of care using the I-NIC model. Interviews with nursing leaders elicited leadership perceptions on management of the integrated units, including staffing, implementation, and budgeting. Interviews with parents (mothers and/or fathers) of infants admitted to the I-NIC unit focused on the patient and parental experience.

Data Analysis

Field notes that were independently collected by two investigators during the naturalistic unit observation were compared and collated until reaching consensus. Interview transcripts were analyzed using the constant comparative method³⁰ to identify major and minor themes related to the study aims. Data were analyzed as an aggregate, rather than by role (e.g., parent vs. staff), to provide a nuanced and complete description of the I-NIC model and to reflect FCC principles. Interviewer field notes were used to supplement the transcripts and validate identified themes. All authors participated in analysis and discussed themes until reaching consensus. Although our study was not designed to validate the final themes with participants, initial themes were shared with unit leadership following analysis to provide additional rigor and strengthen confidence in the results. Unit leaders stated themes were valid and relevant.

RESULTS

Aim 1: I-NIC model characteristics

Following naturalistic observation, two investigators described the physical layout of the I-NIC unit, staffing patterns and training, and implementation.

Physical layout

To allow for the integrated care of both a postpartum patient and a newborn requiring intensive care, the physical layout of the I-NIC room differed from a traditional NICU or LDRP room. It is important to note that prior to integrating neonatal intensive care into the LDRP space, the I-NIC patient rooms were individual LDRP rooms meeting the corresponding size and equipment standards set forth by The Facility Guidelines Institute.³¹ In addition to meeting LDRP room standards, the I-NIC rooms were equipped with additional oxygen and suction columns and new signage to specify these columns as NICU-equipped. Because The Facility Guidelines Institute specifies that LDRP rooms must have space for the infant following birth that is separate from the mother,³¹ no major architectural changes were necessary when integrating NICU care in the existing LDRP space. The integrated unit had 23 I-NIC rooms. Figure 1 provides a visual of an I-NIC room that includes NICU equipment within the existing LDRP space.

Figure 1.

I-NIC room with NICU equipment

As most neonatal equipment is mobile, the necessary equipment was easily transferred and set up in the existing LDRP rooms when an infant requiring intensive care was admitted. Some I-NIC rooms, like the one depicted in Figure 1, were set up with necessary NICU equipment in an empty room before an admission to ensure preparedness. Other NICU equipment (e.g., isolettes, ventilators, IV poles) were stored in various storage rooms on the unit. Rooms with I-NIC patients were identified by signs on the door (see Figure 2).

Figure 2.

I-NIC door sign

Staffing Patterns and Training

As part of the observation, two investigators reviewed basic staffing and admissions data from 2019 provided by the unit leadership. In 2019, the combined LDRP (23 private patient rooms) and I-NIC unit (23 neonatal beds integrated in each LDRP room) was staffed by LDRP registered nurses (RNs). (16.8 full time equivalents (FTE) plus 4 registry RNs), NICU RNs (14.3 FTE plus 4 registry RNs), and licensed practical nurses (LPNs) (1.6 FTE). Additional clinician and patient care support were provided by obstetrical technicians (4.7 FTE plus 1 registry technician), health unit coordinators (2.8 FTE), lactation consultants (0.8 FTE), and clinical nurse specialists (1.0 FTE). Providers on the unit included 3 obstetricians, 2 locum obstetricians, 2.5 neonatologists, and 6 midwives. The unit’s staffing model was 1:1 for active labor patients, 1:2 for non-laboring patients, 1:1 for ventilated infants, 1:2 for infants receiving CPAP, 1:3 for all other I-NIC infants, and 1:3 for postpartum couplets. To support unit and care delivery cohesiveness, one nurse manager oversaw the LDRP and I-NIC unit and supervised both the LDRP- and NICU-specialized nurses and support staff.

All RNs in the I-NIC model of care were trained in mother-baby couplet care in addition to their specialty expertise (e.g., labor, NICU). In the I-NIC model, a parent-infant dyad may not have the same nurse throughout their care. If an infant required intensive care, they would be assigned a NICU RN in addition to the RN assigned to the postpartum patient. Even though nurses were cross-trained to provide care for perinatal, postpartum, or neonatal patients, nurses specialized in care for one population and would be assigned accordingly. In addition to RNs, LPNs and unlicensed personnel (e.g., patient care technicians) received training to assist nurses with mother-baby care under the I-NIC model.

Implementation and Outcomes

While observing and touring the unit, investigators reviewed a poster presentation describing the model and a DNP final report³² and discussed development and implementation of the model with unit leaders. As part of a DNP and QI project, the unit evaluated length of stay, weight gain, breastfeeding, unplanned extubations, nosocomial infections, and unplanned central line dislodgments using a pre-I-NIC implementation (N = 25) and post-implementation (N= 25) cohorts matched by admission diagnosis, oxygen requirement, gestational age +/− 3 days, and weight +/− 500 grams. Infants in the I-NIC model had higher breastfeeding rates and greater weight gain, while length of stay and safety outcomes (unplanned extubation, central line dislodgement, nosocomial infection) were similar for both cohorts.³²

Aim 2: Perceptions of I-NIC clinical staff

Participant Demographics

Eleven participants were recruited and interviewed. One participant was an obstetrical technician, three were NICU parents (two mothers and one father), three were RNs (NICU; birth center), two were unit leaders (i.e., department director, unit nurse manager), one was an obstetrician, and one was a neonatologist. Each staff member or provider interviewed was present during the transition to the I-NIC model. Additional demographic characteristics of healthcare worker participants are described in Table 1. Specific demographic characteristics of parents were not collected to protect confidentiality and anonymity.

Table 1.

Demographic Characteristics of Healthcare Worker Participants (N = 8)

Characteristic	n (%)
Years of Experience on Current Unit
Less than 5	1 (12.5)
5–10	3 (37.5)
>10	4 (50)
Age in Years
20–30	1 (12.5)
30–40	2 (25)
>40	5 (62.5)
Female Gender (n, %)	7 (87.5)
Race and Ethnicity
White non-Hispanic	5 (62.5)
Black	1 (12.5)
American Indian	1 (12.5)
White and Hispanic	1 (12.5)

Themes

We identified five major themes using the constant comparative method: 1) high satisfaction with the postpartum experience; 2) I-NIC rooms increased family comfort and involvement in care; 3) the I-NIC model increased intradisciplinary communication; 4) providing intensive care in a non-ICU setting was challenging for clinicians; and 5) NICU parents felt a decreased sense of community. There were additional minor themes identified that supported each of the major themes (Table 2).

Table 2.

Major themes, minor themes, and supporting quotes.

Major theme	Minor theme	Exemplary Quote
High satisfaction with the postpartum experience	Increased time with infant	I don’t have to split time between my wife in Labor and Delivery and my baby in the NICU.
	Improved transition to parenthood of a NICU baby	Most moms don’t plan on having a NICU baby, so this helps moms’ transition better when baby is in the room with her. I have seen a huge shift in mom after delivery when mom is able to stay with her baby.
I-NIC rooms increased family comfort and involvement in care	Physical space creates a positive experience	Coming from a mom who had a baby in the old NICU, I had to sleep on a tiny couch in the corner right after my c-section. This [I-NIC] really lets the moms be with their baby and be comfortable. I think it’s great. We’re more able to stay with her [baby] until she is ready to go home since this is our room and we don’t have to share
	Opportunities to bond with baby	It’s [I-NIC] more comfortable…you don’t have to share those first moments with other parents Before [I-NIC], skin to skin was initiated later, breastfeeding didn’t start as soon, and there was less bonding…now sicker kids do skin to skin
The I-NIC model increased intradisciplinary communication	Nurses work as a team	All the nurses [NICU and L&D] work mother baby so that both have some experience with both mom and baby and can jump into an emergency on either end
	Availability of consulting providers	Neonatology is able to consult ahead of time on more moms, so Mom isn’t left to wonder what is happening with her baby There is better anticipatory guidance to moms OB knows more about what is going on with the NICU baby, which allows for better collaboration between both teams
Providing intensive care in a non-ICU setting was challenging for clinicians	Decreased space during emergencies	If there are two emergencies at the same time, it is unsafe…safety was a challenge in the beginning, and it did not feel safe originally When there is an emergency there is not enough space
	Decreased visibility of critically ill infants	[I-NIC was a] huge adjustment because there’s no windows and monitors aren’t visualized easily…it’s very scary as a NICU nurse if you can’t monitor your patient Sicker kids need consistent monitoring and it’s not safe to have them in the same room as mom…this is not an ICU set up specifically and the same safety conditions are not in place
	Physical space limitations cause bed management issues	[I-NIC] can be a problem if we have several [NICU] babies and we are then out of labor rooms since the babies are occupying them. The biggest challenge is space. If a baby is staying for multiple months, then the labor room isn’t available for use.
NICU parents felt a decreased sense of community		In the traditional NICU parents can easily bond with other parents and feel a sense of community
		Here [I-NIC], parents might be surrounded by a well-baby, which can feel isolating

High satisfaction with the postpartum experience

Parents reported positive postpartum experiences within the I-NIC model and described a sense of relief after delivery by receiving care in the integrated care model. They reported that the ability to remain with their newborn after delivery eased the transition to parenthood and reduced anxiety. Additionally, partners of birthing patients reported less stress and more comfort in the hours post-delivery because they did not have to choose where to be (e.g., LDRP unit or NICU unit) and could support their partner and newborn in the same room. Overall, participants positively described the I-NIC model and noted that it allows for increased bonding time with their infant and partner. One provider summarized how the model aids in the transition to parenthood: “most moms don’t plan on having a NICU baby, so this helps moms transition better [to postpartum] when baby is in the room with her.”

I-NIC rooms increased family comfort and involvement in care

The physical space of the I-NIC rooms was described as “more comfortable for the parents” when compared to traditional NICU settings. One parent noted that she “had to sleep on a tiny couch in the corner [of the NICU room] right after my c-section” with her first newborn who was admitted to a traditional NICU. With her second baby, she described being able to benefit from the I-NIC model and noted that it gave her a greater sense of comfort to have a “real bed” and a room that she “didn’t have to share.” Other participants described the private rooms as allowing for increased opportunities to bond with their newborn. Similar to SFR layouts, the I-NIC rooms allowed parents to participate in skin-to-skin care and breastfeeding in a private, intimate setting. Nurses elaborated on this theme and noted that before implementing the I-NIC model, “skin to skin was initiated later, breastfeeding didn’t start as soon, and there was less bonding” for NICU families.

The I-NIC model increased intradisciplinary communication

Nursing staff noted that sharing space with LDRP nurses, NICU nurses, obstetricians, and neonatologists enhanced intradisciplinary communication. In the I-NIC model, LDRP nurses and NICU nurses worked collaboratively and side-by-side to provide care to the birthing patient and their infant. During implementation of the I-NIC model, LDRP and NICU staff were trained in maternal-infant couplet care. Nurses reported that collaborative training and practice bolstered a sense of community and knowledge across specialties. Further, nurses were positioned close to one another to help in the event of an emergency. From the provider perspective, prenatal consultation was easier to conduct, as neonatologists and obstetricians shared a workspace, and this enhanced collaborative environment allowed for “better anticipatory guidance to moms.” Additionally, obstetricians and LDRP staff were better able to support parents during the transition to parenthood because they “know more about what is going on with the NICU baby.”

Providing intensive care in a non-ICU setting was challenging for clinicians

A significant challenge of providing neonatal care within the I-NIC model was that the I-NIC unit “is not a [traditional] ICU.” While the lack of an ICU environment (e.g., traditional doors vs sliding glass doors, closed doors vs open doors, easily visible patient monitors vs patient monitors visible only inside the patient room) may create a more comfortable experience for parents, it also led to safety concerns for staff. One nurse said, “there’s no windows and [bedside] monitors aren’t visualized easily…it’s very scary as a NICU nurse if you can’t monitor your patient.” This lack of visibility into the room itself created hypothetical safety concerns for some nurses. Because patients requiring intensive care are critically ill, “[they] need consistent monitoring and it’s not [always] safe to have them in the same room as mom.” Although these concerns were noted, interviewer field notes identified centralized monitors at the nursing station for all NICU patients. Thus, this concern may stem from the lack of immediate visualization of the newborn, as in where monitoring occurs, and not the actual ability to monitor newborn status. Lastly, clinicians and unit leaders reported that rates of infection did not increase and there had been no unplanned extubations of central line dislodgement since implementing the model.

In addition to safety concerns, integrated postpartum care for mother and baby may create bed management issues. Because infants remain in the same room even after maternal discharge, less labor rooms are available at any given time. For large medical centers, this may be a “significant barrier” to implementing the I-NIC model of care. Nurse managers commented that, “the biggest challenge is space…if a baby is staying for multiple months, then the labor room isn’t available for use.”

Potential for decreased sense of community among NICU parents

In the I-NIC model, NICU parents remain in the same room in which they delivered. Because of this, parents reported the potential for a decreased sense of community for parents of NICU infants. A NICU parent described that in a traditional NICU setting, “parents can easily bond with other parents and feel a sense of community.” However, with I-NIC care, NICU parents are “surrounded by well-babies, which can feel isolating.” Often parents cannot plan or do not anticipate their newborn will need intensive care, so the sense of community provided by a traditional NICU can be helpful to ease the transition to parenthood and challenges associated with parenting a NICU infant.

DISCUSSION

This is one of the first studies to describe the I-NIC model. The I-NIC model combines the positive aspects of FCC models and SFRs to improve care and outcomes for NICU families. Although the approach is novel and well-received by clinicians and patients in our study, the model may not be applicable to all care settings. Implementation of the I-NIC model may be challenged by many barriers (e.g., architectural, unit culture, staffing); however, overcoming these challenges and successfully integrating neonatal intensive care within maternal care settings can contribute to better outcomes for organizations, clinicians, birthing patients, and infants. Furthermore, there are important clinical outcomes that may justify this model such as increased rates of chest feeding and skin-to-skin care, no excess safety events, improved parental mental health and role transition, and cross-trained staff.

Integrating NICU care into other units is a novel approach but is not entirely new. Previous studies have described integrating NICU and postpartum care into a single unit. For example, in British Columbia, de Salaberry and colleagues described the MotherBaby Care Unit, in which low risk mothers and infants requiring level 2 neonatal care were cared for by one NICU nurse who received additional postpartum training.²⁸ A similar model, implemented in India, has been described by Chellani and colleagues.³³ In these models, infants and their mothers received postpartum and neonatal intensive care in dedicated, single-family rooms in the NICU, rather than on the LDRP or postpartum unit.

When considering the applicability of implementing an integrated NICU into an LDRP or postpartum unit, it is important to note the level of neonatal intensive care required. Similar to Salaberry and colleagues²⁸ and Chellani and colleagues³³, the I-NIC model described in this study was implemented in a Level II neonatal care unit. Infants requiring Level III or IV treatment and intervention (e.g., prolonged mechanical ventilation, high frequency oscillatory ventilation, surgical services, extracorporeal membrane oxygenation),³⁴ may not be well-suited for this model and a traditional NICU space may be required to ensure patient safety. Although it is unknown whether this model would be effective in higher acuity settings such as Level III or IV NICUs, family-centered care models (e.g., FICare, Close Collaboration) have been implemented with higher acuity patients effectively in the NICU. For example, in Finland, a new NICU was designed to include an adult sized bed in a NICU single-family room along with the infant equipment to improve family-centered care.²⁶ The I-NIC model is unique in that it adds a NICU bed to a family birth center room rather than adding an adult bed to a NICU room. It is unknown if the I-NIC model could be successful in higher acuity settings, thus warranting a feasibility study and further investigation into the barriers, facilitators, and effectiveness of the I-NIC model in these higher acuity settings.

Concerns regarding patient safety were identified in this study; however, in our study, and in both studies by Salaberry and colleagues²⁸ and Chellani and colleagues³³ no safety events were reported by leadership, and safety concerns raised by participants were hypothetical. Nevertheless, patient safety is of utmost importance and all safety concerns, realized or anticipated, should be carefully considered. Concerns raised by clinical participants included a decreased ability to visually monitor the infant from outside the patient room as well as their interactions with visitors, the heightened complexity of the care environment resulting from adding intensive care personnel to an already established unit, and the potential for running out of patient beds or the need for higher acuity services. Organizations that deem the I-NIC model as a viable and desired approach to NICU care delivery, should identify these and other potential safety concerns, and develop policies and practices to mitigate these concerns and ensure safety.

Another important consideration to implementing the I-NIC model is the effect on unit culture. In our study, NICU nurses reported that after implementing the model, they felt their identity as a NICU nurse and their identity as a NICU care team diminished. Coordinating maternal-infant services is considered an effective approach to improving care delivery, reducing waste, and improving patient satisfaction.^35–37 Interdisciplinary care has been shown to improve team dynamics, efficiency, effectiveness, and clinician satisfaction.³⁸ However, failure to consider the social dynamics among clinicians and leaders of an integrated unit prior to and during implementation, may have deleterious effects on the unit culture and milieu. Implementation science provides numerous recommendations and frameworks for evaluating and addressing these important barriers (e.g., poor unit culture; miscommunication; lack of resources) such as engaging stakeholders early and often, communicating about the change clearly and openly, and identifying resources and interventions to support interdisciplinary care teams. Integrating new care models, like I-NIC, may involve investigating and addressing perceptual differences in implementation leadership and climate between leaders and staff to create a more conducive implementation environment to support successful implementation and sustainability.³⁹

The I-NIC model contributed to improved patient outcomes as noted by participants in our study. Parents and nurses stated the I-NIC model improved chest feeding and maternal-infant bonding outcomes. This aligns with findings of previous studies investigating integrated care models.^{28, 33} Further, the I-NIC model was reported to improve parent satisfaction in our study. Future studies are needed to examine additional benefits of the I-NIC care model and should include outcomes similar to those promoted by single-family rooms and family-centered care such as decreased parental stress, increased parental confidence, increased quality of care, increased chest feeding, improved maternal infant bonding, and decreased length of NICU stay.^{12–17, 26, 40}

Limitations

This study has numerous limitations. Only one site was included, but to our knowledge, this is the only site in the United States that utilizes this approach to combine postpartum and NICU care. Although a diverse sample was interviewed, participants may have agreed to interviews because they had strong opinions (whether positive or negative) regarding the I-NIC model. Future studies should recruit larger samples of clinicians and parents respectively to explore perceptions of the I-NIC model by role. Another limitation of this study is the limited qualitative information gathered around safety issues and any potential concerns of postpartum mothers. While we were not able to address these concerns explicitly, in our observational notes, the authors did ask about safety events and adverse events reported such as unplanned extubations, and the leadership stated there were no additional safety events; however, they were unable to provide data to support this. Thus, it is reasonable to consider the possibility that there are no greater safety risks in this environment than in other settings; however, future research is warranted to investigate safety and adverse events associated with the I-NIC approach. Additionally, future studies can focus on measuring maternal and infant outcomes as they relate to the provision of combined postpartum and neonatal intensive care.

Conclusion

Overall, combined NICU and LDRP or postpartum care models, such as I-NIC, can promote positive maternal and infant outcomes. While these care models are novel, their applicability is diminished by many factors such as unit architecture, level of NICU care services, and patient census. Further, very little is known regarding factors surrounding its implementation (e.g., sustainability, feasibility), safety (e.g., level of NICU care provided, appropriate cross-training methods for staff nurses), and outcomes (e.g., chest feeding, length of NICU stay, maternal infant bonding, postpartum depression). Future studies should investigate the aforementioned factors among others to provide a more robust and comprehensive understanding of the I-NIC care model and its implementation.

ABBREVIATIONS

NICU

Neonatal Intensive Care Unit

SFRs

Single-Family Rooms

FCC

Family-Centered Care

I-NIC

Integrated Neonatal Intensive Care Unit

LDRP

Labor, Delivery, Recovery, and Postpartum Unit

RN

Registered Nurse

LPN

Licensed Practical Nurse