Nurses' Perception of Family-Centered Care in Neonatal Intensive Care Units

Abstract

Family-centered care (FCC) is one of the important elements of care in neonatal intensive care units (NICUs). The aim of this study was to understand the nurses' perception of FCC in NICUs. This qualitative study was performed using conventional content analysis. Participants in this study included 18 nurses who were selected by a purposeful method. Semistructured, in-depth and face-to-face interviews were conducted with the participants. All interviews were written down, reviewed, and analyzed. Two categories were identified after the data analysis: (1) prerequisite for providing FCC and (2) parents' participation. Prerequisite for providing FCC consisted of two subcategories namely suitable facilities and adequate personnel. Parents' participation included subcategories of parents: neonate's attachment and parents' training. Nurses' perception of FCC in NICUs can facilitate an appropriate condition for the participation of family members in the care of neonates.

Introduction

Neonatal intensive care units (NICUs) are stressful environments, ¹ and hospitalization of premature neonates in NICUs is inevitable. ² Also, since NICUs are stressful environments for parents, the necessity of paying attention to these parents is felt evermore. ³ Parents of hospitalized neonates in NICUs think that as they have entered into an unfamiliar environment, they have no control over it. ⁴ Furthermore, after neonates' hospitalization, parents feel guilty, ⁵ which causes many parents to experience emotional distress. ⁶ Meanwhile, family-centered care (FCC) is one of the important elements of the care of neonates ⁷ which has a protective effect on parents. ⁸ FCC in NICUs does, in fact, officially recognize the effect of family on the health of neonates. ⁹ It is believed that a family has an active role in providing emotional support to a neonate. ¹⁰ FCC in NICUs is a holistic and comprehensive care that considers the differences in families, their individualities, and their dignity. ¹¹

The single-room design is recommended in NICUs. Access to single-room areas is necessary for the care of hospitalized neonate in a private place. FCC requires parents to have access to bedrooms near the NICUs, so-called family rooms or chat rooms. This design facilitates FCC through increased family participation and improves health care team's perception of work quality in terms of improved communication, ability to concentrate on the job, and provision of privacy for families. ¹² A less-fragmented communication creates better opportunities to provide support for parents in the unit with single-room design. ¹³

Several studies throughout the world have taken into consideration the value of providing the attention to neonates in NICUs and the necessity of FCC. Whenever Swedish families observed disruptive care of their neonates, they experienced considerable stress and insomnia. ¹⁴ Jordanian parents stated that the support of health care team decreased their tension and stress. ¹⁵ Iranian researchers stated that it is necessary for the health care team in NICUs to plan care based on families' values and beliefs, and in this way, they can support families. ⁹ The most important concern of Swedish parents regarding the discharge of their neonate from NICU was their unreadiness for discharge and lack of information, especially about neonates' nutrition. ¹⁶

Our literature review revealed that there is a need for attention to the families of hospitalized neonates from hospitalization to discharge. It is important to build a full understanding of factors that influence FCC in NICUs. In this regard, nurses' perception plays a key role in the effective implementation of family involvement in NICUs. FCC as a standardized care has not been implemented properly in NICUs in Iran. Also, the positive involvement of nurses in FCC has not yet been fully integrated into NICUs' practice in Iran. Thus, studying the NICU nurses' perception of FCC can provide us with the basic knowledge required for implementing this type of care. In addition, this factor can lead to the development of useful strategies to promote better care in NICUs.

Objective

This study was performed with the purpose of understanding nurses' perception of FCC in NICUs.

Methods

Study Design and Population

Conventional content analysis method was used in this qualitative study. The aim of content analysis is to structure the transcript and reduce the complexity of interview material to achieve a deeper level of abstraction. In this study, the Graneheim and Lundman approach was used for content analysis. ¹⁷

In this study, a sample of nurses was selected by a purposeful sampling method. They were chosen using maximum variation method in terms of variables such as age and work experience. Nurses with direct involvement in neonatal care were considered for inclusion in this study. Other inclusion criteria were the interest to make contact with the researchers and the willingness to participate in the study. Accordingly, 18 nurses participated in the study. All nurses were females aged 23 to 42 years and had bachelor's degree in nursing with 4 to 12 years of work experience.

The study settings were two separate level III NICUs in two teaching hospitals affiliated to Shahrekord University of Medical Sciences (SUMS), which are the main referral centers for preterm infants located in the Chahar Mahaal and Bakhtiari province of Iran. Total beds in these NICUs were 24 to 30, with four to seven infants in the same room. These NICUs are representative of all NICUs in Iran. In these NICUs, mothers were free to stay with their infants as long as they want, 24 hours a day. Armchairs were prepared next to the warmers or incubators to help the mothers to stay next to their infants. Other preparations such as food, public rooms for relaxing, and a bathroom were also available for the mothers. However, fathers were given a specific time in the afternoon to visit their children, and their presence on the unit was limited. Also, the presence of other family members such as grandparents was not allowed or was restricted. Parents could also participate in group teaching classes.

Data Collection

In this study, data collection and analysis were conducted simultaneously over a 6-month period in 2017. For data collection, a semistructured interview format was used. Potential nurses were introduced to the researcher by the head nurses, and this provided initial familiarity with the participant. The first author informed each NICU about the study. Also, to ensure that all eligible nurses are given a chance to participate in the study, the units were repeatedly assessed by the first author, covering all shifts (morning, afternoon, and evening). Interviews with participants were performed in three shifts by appointment in personnel room in NICUs, which was a comfortable and secure environment. Interviews were generally conducted on holidays when there was less workload. The interviews were semistructured and face-to-face and were of 35 to 45 minutes in duration. In the interview, first a general question, “what is your opinion about FCC in NICU?” was asked and then it continued with phrases such as “please explain more about this.” Each participant was interviewed once, and a total of 18 interviews were conducted. Interviews were continued until data saturation was reached. Data saturation means that the participants cannot produce any new data and the information is repetitive. The participants' answers were recorded using a voice recorder.

Data Analysis

Content analysis was used to classify the interview data. The following steps were taken. ¹⁷ First, the interview transcripts were read several times to achieve an overall sense of the whole. Second, the text was divided into compacted semantic units. Third, the compacted semantic units were given codes. Fourth, the codes were divided into categories and subcategories based on their similarities and differences. Fifth, categories were formed as the expressions of latent content of the text.

Criteria of credibility, dependability, confirmability, and transferability were used to evaluate data accuracy. ¹⁸ To ensure the data credibility, a constant engagement with the subject and data was made, and the comments of research team members concerning the procedure of interviews and data analysis were considered. Texts of the interviews and findings were shared with some of the participants and they agreed that the results fit their perception. For data dependability, we used opinions of a foreign observer as a researcher who was familiar with the clinical nursing and methodology of qualitative research but was not a member of the research team, and an agreement on results was made. To determine the confirmability of data, a report of the research process was prepared. Transferability of our study was determined by reporting a complete description of participants and context. The study data were analyzed by the first author, and then the second author got involved in data analysis and reexamined the categorization. The researchers agreed with the content of extracted categories.

Ethical Considerations

This study was registered with the no. 2345 in the health modeling center of SUMS. To observe ethical consideration, permission was obtained from the Ethics Committee of SUMS. Written consent was obtained from all participants. Also, while giving information about the research objectives and obtaining consent for voice recording, the participants were assured about the confidentiality of their information. In addition, they were informed that they could leave the study whenever they want, but none of them left.

Results

Two categories were identified in this study, namely prerequisite for providing FCC and parents' participation.

Prerequisite for Providing FCC

The personnel stated that suitable facilities and adequate personnel are the prerequisite for FCC.

Suitable Facilities

Employees emphasized on the equipment deficiency and unreadiness of the unit for implementing FCC. For example, they pointed out a lack of necessary physical space in this regard. “There is no place here and the mothers find a small place with difficulty; the fathers cannot stay here because we have no accommodation for men!” (nurse 4).

The nurses emphasized on the necessity of the separate room for neonates in case of suitable facilities. They believed that two or several neonates in one room make parents uncomfortable. In this regard, participants pointed to the concept of cultural shame in Iranian culture. It would be so much better if the neonates' room could be separated. “A mother sitting and breastfeeding her child is irritated if a father of another child enters into the room. The mothers feel ashamed if a stranger sees their breast. This shame is in Iranian culture. It would be so much better if the neonates' room was separated. We cannot allow fathers to come in the unit due to the poor facilities and little space” (nurse 9).

Adequate Personnel

Study participants pointed out the necessity of having an adequate number of nurses for providing FCC efficiently in NICUs. Furthermore, when there is a shortage of nurses in NICUs, FCC structures cannot be implemented properly and efficiently in Iran. According to the participants, shortage of personnel is an obstacle for providing FCC because it imposes too much workload on the nurses. “For implementing FCC, we need adequate number of nurses. Here the ward is very crowded and there are a lot of patients but few nurses” (nurse 10).

“The little number of nurses results in an increased workload, and this pressure is an obstacle to the implementation of FCC. When there are few nurses, we cannot spend time with the parents and listen to what they say about their children, and this makes them think that they are being ignored” (nurse 14).

Participants believed that the shortage of personnel results in parents' dissatisfaction with the care, and this can be considered as an obstacle to the implementation of FCC. “I have seen many times that following insufficient number of nurses, good services are not provided for parents, and this brings about their dissatisfaction. Undoubtedly, insufficient number of nurses will have unfavorable consequences because with parents who are dissatisfied, we cannot think about FCC. Besides, parents' dissatisfaction with the health care team will have a negative effect on the relationship between parents and the health care team” (nurse 18).

Parents' Participation

Parents–Neonate's Attachment

Participants believed that voluntary participation of parents in the care of their infants will decrease their stress and facilitate the provision of FCC. “When parents participate in the care of their neonates, they are somehow protected because they are so worried about their child's condition” (nurse 8).

However, sometimes parents' family problems such as taking care of other children, housekeeping, and unwillingness to stay at hospital for long term are impediment to parents' presence beside their neonate. “Last year, we had a very unwell patient in the ward, and I asked her parents to stay more and to be more available. At least her mother could stay, but they said that they don't like to stay at hospital for long time” (nurse 15).

Participants stated that FCC will result in solidarity between family members and neonate, but they believed that a phenomenon called “cultural transition” can create an obstacle in this regard. Today, expanded changes have occurred in the family nuclear in Iran due to cultural transition. These changes have reduced the support of grandmothers and grandfathers in the care of hospitalized neonates. This important cultural factor is a barrier to performing FCC. “Parents' presence and even grandparents' presence in NICUs is very good. This presence will create the maximum closeness between parents and neonate. Unfortunately, cultural transition of our society has made the role of grandparents less visible” (nurse 3).

Parents' Training

In the view of participants, training which is provided for parents by nurses will result in parents' better participation in FCC. This training is dependent on the physical space of the unit and the conditions governing it, as well as breastfeeding. “When parents come to be with their child, we first train them to wash their hands, and inform them about conditions here and how they should enter the unit. These will help them to further participate in the care of their child” (nurse 2).

Nurses stated that one factor that hampers their ability to train parents in the field of FCC and to see the results of parents' participation in a neonate's care is the lack of clarity in training of the nurses in theoretical and clinical aspects of FCC. “Unfortunately, pediatric nursing program at the bachelor's level insufficiently covers the concept of FCC. More training should be provided so that the nurses can give parents comprehensive training in this regard. Certainly, later they will cooperate more with us in the care” (nurse 12).

“Neonates' nurses should increase parents' skills for participation in the care process, but FCC has not been practically clarified for us so that we can help parents in this regard” (nurse 5).

Discussion

In this study, perception of Iranian nurses about FCC in NICUs was investigated. As stated by the participants, providing this type of care is dependent on suitable facilities and having enough personnel. Some organizational factors such as limited space within the NICUs are barriers to the implementation of FCC. In this regard, the result of a study in Finland revealed that families' allocation in private rooms will increase interactions of nurses with parents of hospitalized neonates in NICUs. ¹³

Our participants believed that mothers endure a kind of shame that is rooted in culture and is called cultural shame. This means that due to the lack of proper physical space, mothers were forced to breastfeed their neonate in the presence of the fathers of other neonates. In the cultural context of Iran, men's presence as non-mahram (men who are not allowed to see a woman without hijab) next to a woman who is breastfeeding her child is wrong as it is obligatory for women in Islam to cover their body parts from men. Therefore, the presence of a non-mahram man causes mothers discomfort in the NICU. This finding indicates that the Iranian society should carefully identify elements affected by culture to provide FCC in NICUs and then should plan to overcome these cultural barriers.

According to the results, lack of adequate personnel in NICUs inhibited them from spending enough time with the parents; therefore, they were not aware of parents' concerns about their neonates. Based on a study in Norway, when nurses pay attention to parents' point of view about their neonate's care, they cope better with the hospitalization of their child. ¹⁹ The results of a study in Germany revealed that effective and empathetic relation between parents and nurses decreases family tension. ²⁰ Our participants stated that problems such as housekeeping and having other children will result in the absence of parents in the unit, and this disrupts parents–neonate's attachment. In a study which investigated the parents of neonates hospitalized in NICUs in European countries, the most important factor in parent–infant closeness was the continuous presence of parents in NICUs. ²¹ However, the results of a study in China showed that sometimes parents are faced with some limitations, and neonate's care is performed with the minimum participation of parents. ²²

The study participants stated that cooperation of other family members such as grandparents with parents results in a better provision of FCC. Meanwhile, participants believed that the phenomenon of “cultural transition” was an obstacle to provision of FCC in the Iranian society. The Iranian society in its transition from a traditional society to a modern one is faced with a phenomenon, which has turned the extended family into a nuclear family. An extended family offers many advantages including participation and physical and psychosocial support, particularly in times of major problems. Iranians are very committed to having close relationships with their family and providing care for a sick family member. However, a nuclear family has lower levels of these altruistic behaviors than the extended family. It seems that cultural transition constitutes a challenge to Iran's health system.

Our study revealed that parent' training results in more cooperation with the health care team. Results of another study in Iran revealed that parents of hospitalized neonates wish to receive information related to their neonate from the health care team. ²³ Our study also showed that one item that affects parents' desirable participation in their neonate's care is the lack of FCC topic in the nursing curriculum. Therefore, the custodians of Iran's nursing education can consider these results and seriously revise the nursing curriculum. As stated by the participants, providing families with comprehensive information about FCC through a training program will ultimately attract families' attention toward participation in the care of their infants. The result of a study in Ireland revealed that based on nurses' point of view, noncooperation of families was one of the obstacles for implementing FCC. ²⁴

This study had some limitations. One of these limitations was related to the nature of qualitative research, in which there are a few participants. Moreover, not employing male nurses in NICUs, which is obligatory in the Iranian nursing system, resulted in all nurses of this study to be females and, therefore, we missed the perspective of male nurses in this regard.

Conclusion

Although FCC is not a new concept in the field of neonates, the results of this study revealed that in some countries including Iran, FCC is not being ideally implemented. Iranian hospitals do not have enough facilities to provide FCC in NICUs. In this regard, lack of physical space and shortage of nurses are the most important factors that require the attention of health policymakers. Necessary structures to provide this kind of care are not seen as essential. With regard to these points, Iran's health care system and its policymakers should fund the construction of FCC in the NICUs, which necessitates hiring more staff, providing single-room NICUs, paying for parents' transportation to NICUs, educating nurses about FCC, and paying attention to the cultural elements of the society.

Funding Statement

Funding This work had no external sources of funding.

Erratum: The affiliation of author Haydeh Heidari has been corrected as per Erratum published online on September 9, 2019. DOI of the Erratum is 10.1055/s-0039-1697038.