Improving Family-Centered Care Practices in the NICU Laurie A. Lee, DNP(c), APN, NNP-BC Melondie Carter, RN, DSN Sharon B. Stevenson, DNP, APRN, PNP-BC H. Allen Harrison, MD, BSN Disclosure The author has no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article. No commercial support or sponsorship was provided for this educational activity.
ABSTRACT Family presence and participation in care in the NICU is fundamental to the recovery and well-being of the sick neonate and family. However, some NICU visitation policies are not supportive of families. A new visitor-management program was initiated at a local hospital. The program included open visitation for parents and others chosen by parents to be a support during their hospital stay. This qualityimprovement project evaluated if there was any improvement in parents’ perceptions and experiences of family-centered care after the implementation of the new visitor-management program. The NICU parent survey data revealed a modest positive difference in parent responses after the implementation of the program. Keywords: family-centered care practices; visitation guidelines; visitor management; NICU
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Accepted for publication November 2013.
birth of an infant who requires hospitalization is a very stressful event. This crisis interrupts parent–infant attachment, which may have lifelong effects.1 Parental roles may change significantly when their infant becomes hospitalized.2 Family-centered care provides support for families who may experience stress, fear, and difficulty with parenting roles when they are in the hospital with their sick newborn infant.1 Parents reported that, when they are not able to help, hold, and care for their infant; protect them from pain; and share the infant with other family members, they experienced symptoms associated with acute stress disorder.3 Encouragement of family presence and participation in caregiving activities can help parents assume their priceless role at their infant’s bedside and help to decrease their stressful feelings. Family presence and involvement is essential to the health, recovery, and well-being of the infant in the NICU. Families, especially parents, can be the best advocates for their infants who have
a wide range of developmental, social, and emotional needs.4 Removing the barriers to family presence and participation is imperative for parents to feel welcomed and valued in an environment that is both unfamiliar and challenging. An essential step in the removal of barriers for families is to examine the unit’s visitation guidelines. These guidelines will provide some important clues to the openness and inclusiveness of the unit to our parents, families, and friends in their greatest time of need. A review of unit guidelines will also indicate the degree to which we are practicing the principles of family-centered care. In a review of the NICU policies regarding the provision of family-centered care, it was determined that the visitation policy was outdated, restrictive, and not welcoming to our parents or their families and friends. In the old policy, parents and grandparents were the only individuals who could spend time with the infant on their own. They were not allowed to enter the nursery until a unit
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secretary called the bedside nurse to determine if they could come to their infant’s bedside. They could not enter the NICU during change-of-shift report times or during other unit activities. Other family members or friends would not be allowed to visit the infant unless one of the parents was present at the bedside. There was no mechanism in place for parents to identify friends and family they would like to have as support systems while their infant was in the NICU. Some parents revealed their concerns about the restrictive visitation practices through the NICU parent survey and in their conversations with the nurses and nurse practitioners. They wanted the individuals in their support network to be able to spend time with their infant when they could not be at the hospital. Parents also wanted to stay with their infant during shift change instead of having to put them back to bed and wait for an hour before reentering the unit to spend time with their infant. This visiting restriction during shift change was especially inconvenient for parents who came to visit their infants after work on their way home. Some parents wanted to be with their infant during procedures to provide comfort and support. Other parents wanted to be present no matter what was going on in the unit. They just wanted to have free access to their infant and to have their family and friends around them during this stressful time. These concerns were brought to our multidisciplinary family-centered care committee for discussion. These concerns were also brought to nursing and physician leaders in the NICU. It was the general consensus of all groups
FIGURE 1
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that we needed to address the needs and requests of our families and provide more open family-friendly visitation in the NICU. A quality-improvement flow diagram was created to help to guide the process and development of the new visitormanagement program. The quality-improvement project aim was to create a family-centered visitor-management program in the NICU. The measure of improvement was defined as a 20 percent improvement between preintervention and postintervention survey scores using the NICU parent survey. Key drivers and processes were identified, and design changes were defined. These details can be seen in Figure 1. A family-centered visitor-management proposal was drafted and presented to several NICU families, the NICU family-centered care committee, NICU nursing and physician leaders, the director of social work services, the vice-president of patient care services, the vice-president of administration, and finally to the chief operating officer of the hospital. The proposal addressed the need to create a family-centered environment in the NICU, which allowed parents to have unrestricted access to their infant, to be able to select family members and friends who will serve as a support network during their hospital stay, and to provide a safe and secure environment for all NICU families and staff members. Support for this initiative was provided, and the proposal was presented to the director of hospital security. After numerous meetings with the hospital security director, staff, and vendors, a visitor-management system was chosen.
Improving family-centered care practices in the NICU.
Improving Family-Centered Care Practices in the NICU
Design Changes
Key Drivers/Processes Project Aim
Aim: Create a familycentered visitormanagement program in the NICU
Measure: There will be a 20% improvement between preintervention survey and postintervention survey scores using The NICU parent survey
1. Review the literature and current NICU policies surrounding visitation in the NICU
2. Talk with families and review NICU parent survey responses regarding familycentered care practices that support family presence
3. Meet with the NICU multidisciplinary familycentered care team, key leaders in the NICU, and the institution to devise a plan supportive of family presence and gather support/funding
a. Change language in NICU visitation policies, orientation to the nursery, and rooming-in guidelines to change perception of the family as visitors
a. Create guidelines that encourage family presence and participation b. Invite parents to identify and utilize a support network during their infant’s hospital stay
a. Pilot a new visitor-management program in the NICU
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The NICU was selected as the unit to serve as a pilot for the hospital visitor-management program. The unit policies were rewritten. Parent and staff materials were updated. Unit secretaries and receptionists were trained how to use the visitormanagement hardware and software. Numerous changes were made in the original “visitation policy” and are reflected in the Family and Friends Guidelines and Orientation in Table 1. All NICU staff members and multidisciplinary team members were informed of the upcoming changes in the visitation policy. Families in the NICU were also informed in person or via a letter of the new guidelines. The NICU visitation policy was retitled, “NICU Family and Friends Guidelines and Orientation.” Parents were given picture badge identification access to their infants 24 hours a day. Parents were able to officially choose family members and friends (a support network) who could come unaccompanied (by parents) to spend time with and care for the hospitalized infant. These individuals were also given picture badges to identify who they were in relation to the infant. Families and staff joined together in this family-centered care venture of open visitation. To try and capture the impact of this new visitormanagement program, data were gleaned from the NICU parent survey regarding parent impressions of family-centered care practices. A retrospective review of survey data was performed three months prior to and after the implementation of the new visitor-management program. It was hoped that the results would show improvement in parents’ perceptions of family-centered care practices in the NICU. NICU staff members agreed, with some trepidation, to support the new open-visitation program for parents and their chosen support network in an effort to improve familycentered care practices. Their reaction and responses to the change in policy were not captured by any formal means. There was some initial resistance to unannounced parental presence at the bedside, which improved over time. The answer to staff’s concern over their lack of control of visitation was to remind them of the importance of this practice to support family-centered care in the NICU. Staff members were also asked to personalize these new practices and visualize their own experiences and needs for family presence when they were a patient in the hospital or had a child or family member in the hospital.
LITERATURE REVIEW
The American Academy of Pediatrics (AAP) issued a policy statement in 2012 surrounding patient and family-centered care and the pediatrician’s role. The policy statement emphasizes that the basis for patient and family-centered care is the recognition that the family is the child’s principle source of strength and support.5 The statement also stresses that patients and families are considered health care team partners, and the perspectives and information shared by families and patients are key to clinical decision making.5
The A AP has identified six core principles of familycentered care. These include the following: 1. Active listening and respect for each child and family member with the acknowledgment of racial, ethnic, cultural, and socioeconomic backgrounds and how they may be used in planning for care delivery. 2. Creating flexibility in policies, procedures, and practices to individualize care. 3. Providing ongoing honest and useful information to patients and families so they can participate in decisions and caregiving. 4. Providing support for the family throughout each stage of the child’s life. 5. Working with families at multiple levels of health care so their contributions can be seen in professional education, policymaking, quality-improvement initiatives, medical research, and family advisory councils. 6. Helping families and children recognize and build on their own strengths, which will build confidence and encourage them to participate in decision making about their own health care.5 The core principles of family-centered care stem from the idea that families can influence the health and well-being of their own family members.6 Because families can have such sway in this area, they need to be supported in their efforts to provide care for the sick family member.6 Some other core principles of family-centered care are described by Johnson. They are (1) treating others with dignity and respect; (2) communication styles and information sharing establish the importance of the individual; (3) families are encouraged to build on their own strengths through activities and experiences that result in greater independence and a feeling of being in control; and (4) care delivery, policymaking, program development, and professional education result from collaboration between patients, families, and providers.6 Johnson also shares four family-centered tenets, which are important in the implementation of family-centered care. They are (1) the constancy of family in the lives of patients, (2) awareness of the many ways that “family” can be defined by patients and families, (3) the importance of buyin from all disciplines and system integration of the family-centered care principles, and (4) extensive patient and family involvement in family-centered care policy and program development.6 NICUs may employ some of the family-centered care tenets and principles in unit policies, procedures, and practices. However, there is always room for growth and improvement in the family-centered care culture of every NICU. Several of the parent needs identified by Cleveland regard parent inclusion in the infant’s care and contact with the infant.2 One of the barriers to the inclusion of parents in caregiving is the actual NICU visitation policy. Gooding and colleagues state that, although progress has been made in expanding visiting hours and encouraging parent presence, many NICUs continue to “close during nursing shift changes and reports, medical rounds, new admissions, emergencies, and neonatal deaths.”4 Gooding and
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TABLE 1
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Family and Friends Guidelines and Orientation
NICU Parents
NICU Siblings
Family and Friends
NICU is open 24 h/d, 7 d/wk. Receptionist will greet parents and explain the NICU Family and Friend’s Guidelines and Orientation to the NICU.
NICU is open for those siblings who are at least 2 y of age for 10–15 minutes at a time so siblings will have a good experience at the bedside.
Family and friends may come with parents from 9 AM –9 PM, 7 d/wk.
Parents choose in writing the grandparents and up to four chosen people with permission to enter NICU without a parent present using the Parental Permission Form.
Complete a Sibling Screening Sheet at reception desk.
Adults may come without parents 24/7 if on the parental permission list.
Family and friends chosen by parents to visit independently may not bring others to visit the infant.
Sibling presence is limited during cold and flu season and also based on unit activity and the attention/behavior of the child.
Children younger than age 14 y are not able to spend time in the NICU unless they are siblings.
Parents may choose not to allow anyone to visit their infant or receive information.
A child life assistant is available to help prepare all siblings for their initial visit. Siblings younger than age 14 y must be supervised at all times by an adult. For the safety of visiting siblings, a request is made that siblings not play on the floor or walk around the nursery when parents are spending time with the infant. Siblings are welcome to spend time in the NICU sibling playroom with a supervising adult or child life specialist. Siblings younger than 18 y of age are not able to spend a night in the Family House.
Because of space limitations, only two people are allowed at the bedside at a time unless the infant is in a private room; up to four people are invited to be at the bedside with the infant and family in a private room.
Check-in Procedure
HIPAA Privacy in the NICU
Infection Control
NICU reception area is designated for check-in and orientation. A welcome NICU Parent Packet is given to parents at time of admission.
For the privacy of others, parents, family, and friends must remain at their own infant’s bedside.
Everyone who visits in the NICU must wash their hands at the scrub sinks at the entry to the nursery or in the area of the infant’s bedside before and after touching the infant or articles at the bedside.
Everyone receives a picture name badge except siblings unless 14 y of age or older. Younger siblings receive an “I am a big brother or big sister” badge.
Nurses may only answer questions about the family’s infant.
Some items are considered “dirty” such as trash can lids, hair, cell phones, and anything that falls on the floor. Hands need to be washed after touching any of these items.
Parents and “chosen” support network will be asked to provide a picture ID which will be used to create a NICU ID badge. They may also be asked to allow a picture to be taken to use for the ID badge if they do not have a current picture ID.
“Chosen” family and friends may receive general information about the infant’s condition during medical team rounds. They may also share in the care of the infant as the infant’s condition permits (such as holding and feeding) per parent preference.
Anyone with signs of illness (elevated temperature, coughing, sneezing, etc.) may not come to the nursery to help prevent the spread of infection to the infants in the NICU.
The NICU ID badge must be worn to enter the nursery and at all times while in the hospital.
To protect the privacy of other infants, pictures may only be taken of one’s own infant. Staff photos may be taken with permission.
Sibling presence is limited during cold and flu season and also based on unit activity and the attention/behavior of the child.
After the badge is received, daily checkin will require everyone to stop at the reception desk to show their badge and use a fingerprint reader for check-in. They will also use the fingerprint reader for check-out.
Toys are welcome at the bedside. However, because of infection control and concerns for infant safety, fuzzy toys or stuffed animals need to remain at home.
Parents and designated family and friends are invited to review the guidelines and orientation with a NICU staff member. They will receive a copy of the guidelines after they have completed their review. (continued)
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Family and Friends Guidelines and Orientation (continued)
Cell Phones/Cameras
NICU Family House (waiting area)
Ronald McDonald House
Cell phones are allowed in the NICU with ringer on vibrate or silent. Cell phones are cleansed with provided wipes when entering the NICU.
A family services assistant is available 7 d/wk from 8 AM to 10 PM.
Located across the street from the hospital for parents
Cell phones may be used for texting; however, for safety reasons, there is no texting when holding infant.
The Family House has chair beds, lockers, and showers for use.
A NICU family services assistant will place parents on a waiting list to stay at Ronald McDonald House.
Use of cell phones for conversations can take place outside of the NICU or in the Family House (waiting area) to help provide a quiet environment for all infants.
As space permits, two sleeping spaces are available to parents/guardians and/ or grandparents; parents who are minors will meet with a social worker to determine their maturity level before they may sleep in the Family House without a grandparent.
NICU family services assistant can also help arrange other lodging as needed.
Families are encouraged to take pictures of their infant(s).
A laundry area and kitchenette is also available in the Family House.
Infant Needs
Additional Information
To promote the healthy growth and development of the infant, voices and noise levels need to be monitored and adjusted while at the bedside to prevent overstimulation of the infant.
Parents are welcomed to call the NICU toll-free number to receive updates and information on their infant. Parents will be given a PIN number to reach the NICU.
Family members are invited to bring socks or booties, clothes, drawings from siblings, pictures of one’s family, and up to two Mylar balloons.
Parents will choose a “code word” to receive information about their infant. If parents choose to share the “code word,” they will be informed that whomever has the “code word” will have access to the infant’s medical information.
colleagues believe that basic components of effective familycentered environments include flexible visiting hours and a culture that makes the entire family feel welcome and valued as “important contributors to the infant’s well-being.”4 The Colorado Consortium of Intensive Care Nurseries (CCICN) analyzed visitation policies of 14 NICUs over a six-year period. The results of the surveys revealed restricted hours for visitation, multiple visitor restrictions including sibling visitation, and authoritarian language in policies that addressed the families’ ability to spend time in the nursery with their infant.7 A consultant helped guide the nurseries to move from “professional-centered family visitation policies to family participation guidelines.”7 At the end of the six-year period, the surveys revealed “more open hours for parents and siblings to be with their baby, less punitive and restrictive language, and a move toward viewing parents as participants in their baby’s care, rather than as visitors.”7 Browne and colleagues believe the creation of family participation guidelines will enhance the family’s ability to care for their infant and help establish critically important parent–infant attachment.7 There is controversy about opening visitation to parents and families in the NICU. According to Krochuk, open visitation or unrestricted access to infants in the NICU should not be the norm.8 Krochuk states that the critical care environment, lack of space around bedsides, the issue of privacy, observations of treatments, and procedures with other
infants are reasons not to permit open visitation.8 Krochuk believes that open visitation may contribute to maternal stress and a feeling of obligation on the part of mothers to be at the bedsides of their infants as much as possible.8 Krochuk proposes that limits should be placed on visitation to help facilitate new mothers’ recovery and self-care behaviors.8 She also states that NICU visitation should be individualized to accommodate the needs of each family.8 Garris, on the other hand, believes that open visitation is a very important part of family-centered care and should be the norm for families whose infants are hospitalized in the NICU.9 Garris states that “open visitation is not only about visiting their baby, but encourages parents and other family members to participate in the care of their ill infants and structure visitation according to their comfort and needs, rather than meeting the needs of the NICU staff.” 9 Garris believes that parents undergo enough stress just with the hospitalization of their newborn infant in the NICU.9 Adding restricted visitation adds more parental stress and anxiety and creates an imposed separation between the parents, family, and their sick infant.9 True advocates and practitioners of family-centered care will have to examine these arguments regarding open visitation in the NICU. They must also be responsible to base their decisions on family-centered care guidelines that have already been established by the AAP and the Institute for
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Patient and Family-Centered Care. A supportive healing environment for sick infants, parents, and family members is one in which there is always a genuine invitation in words and actions for family participation and presence in the NICU.
METHODS
The location for this quality-improvement project is in a 100-bed Level IV NICU that receives, on average, 850 admissions each year. The current average daily census is 70. For several years, the NICU has used a parent survey for ongoing data collection regarding parents’ experiences of family-centered care while their infant is hospitalized in the NICU. All parents who have infants in the NICU for at least two weeks or more are invited to evaluate their NICU stay via the parent survey. The NICU parent survey data are collected through the use of a printed survey tool that incorporates some of the questions from a family-centered newborn intensive care self-assessment inventory. The remainder of the questions in the survey were developed by the NICU family-centered care committee. The original self-assessment inventory tool was published by the Institute of Patient and Family-Centered Care.10 The written introduction of the NICU parent survey informs parents that participation is completely voluntary, and survey responses are anonymous. Parents are also informed that the survey is part of a quality-improvement effort to determine how well the NICU is meeting the needs of our families. They are also told that the information from the survey will be used to educate staff members, develop interventions, and improve practices that will help us meet our families’ needs. The content of the survey includes questions about parents’ first impressions, the NICU environment, caregiving by parents, communication with the health care team, relationships with the health care team, and hospital services. No identifying data are collected. After parents complete the survey, they place the survey in a locked parent survey box at the reception desk in the NICU. Nursing patient care managers retrieve the parent surveys and enter the results into the password-protected NICU parent survey database. The database only contains nonidentified data. The investigator has password-protected access to review the survey results. Because the surveys are only given out once during the infant’s hospital stay, there is no way to perform premeasurements and postmeasurements using the same parent population. A retrospective review of parent survey data was undertaken. The review compared percentages of positive and negative responses in each of the sections of the survey preimplementation and postimplementation of the new visitor-management program. This helped the investigator determine the effects of the program on family-centered care practices in the NICU. All NICU parents were invited to complete voluntary surveys that provided information about their stay in the NICU. Survey responses were anonymous and not linked to any identifying data.
Because this is a retrospective review and no identifying data were collected, risks to the subjects are minimal to nonexistent. There is no direct benefit to the survey participants. The potential benefit of this quality-improvement project is that parents and their support network will feel welcomed and supported by the new family-visitation guidelines and that NICU family-centered care practices will show improvement. Another potential benefit is that parent survey responses may identify other areas that need improvement.
RESULTS
The results of the family-centered care survey are revealed in Figure 2. The second- and fourth-quarter scores reflect the percentage of positive parent responses prior to and after the implementation of the new NICU visitor-management program. Of the 93 surveys obtained during the second and fourth quarter, the overall positive and negative responses for each area were measured. As illustrated, after implementation of the new visitor policies, the positive responses for family first impressions, NICU environment, communication with the health care team, and relationship with the health care team all improved by approximately 5 percent.
DISCUSSION
The parent survey responses indicated that the new visitormanagement program has made a modest positive difference in the parents’ experience and perceptions of family-centered care in the NICU. We did not meet our quality measure goal of 20 percent improvement between preintervention and postintervention NICU parent survey scores. This finding will leave us room for improvement as we continue to work on our family-centered care practices. Some of the questions receiving a high percentage of “always” responses in the fourth quarter were found in four out of five sections of the survey. These sections are family first impressions, communication with the health care team, caring for your infant, and relationships with the health care team. In the fourth quarter, parents rated their feeling of being welcomed in the NICU more highly than those who responded to the parent survey in the second quarter. Parents in the fourth quarter also more highly rated their experience of the NICU as being a caring place. Fourth-quarter parents also believed they received all the information they needed about their infant from hospital staff, were able to understand and read teaching materials, felt supported in breastfeeding, knew their assigned nurse every day, and stated that hospital staff introduced themselves by name each day. These positive responses may be caused in part by the new 24-hour parent access to their infants and more face-to-face interactions with NICU staff members. The parents’ first impressions may have also been influenced by a new reception area and beautiful new Family House waiting room. Fourth-quarter results also revealed a high percentage of “never” responses in two sections of the parent survey. The
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FIGURE 2
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Family-centered care survey results.
Positive Responses Preintervention and Postintervention by Question Type 90.00% 85.00%
% Positive
80.00% 75.00% 70.00% 65.00% 60.00% 55.00% 50.00% FAMILY FIRST IMPRESSIONS
ENVIRONMENT
CARE OF INFANT
COMMUNICATION WITH TEAM
RELATIONSHIP WITH TEAM
2ND QTR POSITIVE
68.57%
75.10%
73.81%
72.65%
61.79%
4TH QTR POSITIVE
73.75%
80.30%
74.71%
77.34%
67.46%
questions were found in the section called caring for your infant and family first impressions. Parents reported that they were never taught how to touch, hold, or be involved in their infant’s care through the use of the “Baby Steps” booklet. The explanation for this result is that the full implementation of the booklet was not complete until after the fourth-quarter survey results were gathered. The survey responses also revealed that parents did not feel their chosen family members or friends were able to hold and care for their infant when they were not able to be in the NICU. It is believed that this negative response may be caused by the newness of the visitor-management procedure as well as incomplete explanations from NICU team members to parents regarding the process of how to build their personal support network for their hospital stay. A major limitation in this quality-improvement project is that we were not able to perform premeasurements and postmeasurements using the same parent populations. Using the same parent populations would have provided more valuable information about parents’ experiences of family-centered care practices before and after the implementation of the new visitor-management program. Another limitation is that we are unable to determine how sick the infants were at the time the parent survey was completed. This may have had a significant effect on the way parents experienced and reported on our family-centered care practices. The location of their infant’s bed, in an open pod versus private room, may have also made a difference in their survey responses. There were several other areas spotlighted for improvement based on parent survey responses. Families indicated that we needed to work on improving teamwork and communication
with families. Several quality-improvement initiatives are under way to address these family concerns. Future study may also include a look at length of stay, acuity, and location of the infant in the NICU because these correlate with parents’ perceptions and experiences of our family-centered care practices.
CONCLUSION
There are several ways nurses can support family presence and participation during the NICU stay. Nurses can skillfully guide families as they learn how to plan and provide for the care of their infant. Nurses can teach families how to work with the health care team and make informed decisions about the provision of quality care for their infants. Nurses can also help families learn how to advocate for their infant throughout the hospital stay, during the discharge process, and in the transition to home or community.11 There are endless ways to promote family presence and participation in caregiving in the NICU. It is so important to try and find the common thread of family centeredness in everything that is said and done for our families. When one is unable to find the common thread, staff members need to stop and humbly ask families for guidance so they will remain on the right path. And as the previously closed doors open to our families, it will be important to remember how critical it is for them to feel welcomed, valued, respected, loved, and cherished throughout the hospital stay. The recovery, health, and well-being of the sick neonate and family receive complete support in a family-centered environment that breeds respect, love, care, and hope for our NICU families.
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REFERENCES 1. Malusky SK. A concept analysis of family-centered care in the NICU. Neonatal Netw. 2005;24(6):25-32. 2. Cleveland LM. Parenting in the neonatal intensive care unit. J Obstet Gynecol Neonatal Nurs. 2008;37:666-691. http://dx.doi.org/10.111/ j.1552-6909.2008.00288.x. 3. Shaw RJ, Deblois T, Ikuta L, Ginzburg K, Fleisher B, Koopman C. Acute stress disorder among parents of infants in the neonatal intensive care nursery. Psychosomatics. 2008;47(3):206-212. http://uams.illiad. oclc.org/illiad/illiad.dll?Action=10&Form=75&value=246245. Accessed November 12, 2012. 4. Gooding JS, Cooper LG, Blaine AI, Franck LS, Howse JL, Berns SD. Family-support and family-centered care in the neonatal intensive care unit: origins, advances, impact. Semin Perinatol. 2011;35(1):20-28. http://dx.doi.org/10.1053/j.semperi.2010.10.004. 5. American Academy of Pediatrics Committee on Hospital Care and Institute for Patient-and Family-Centered Care. Patient-and familycentered care and the pediatrician’s role. Pediatrics. 2012;129(2):394404. http://dx.doi.org/10.1542/peds.2011-3084. 6. Johnson BH. Family-centered care: four decades of progress. Fam Syst Health. 2000;18(2):137-151. 7. Brown JV, Sanchez E, Langlois A, Smith S. From visitation policies to family participation guidelines in the NICU—the experience of the Colorado Consortium of Intensive Care Nurseries. Neonatal Paediatr Child Health Nurs. 2004;7(2):16-23. 8. Krochuk H. Should open visitation be the norm in neonatal intensive care units? Writing for the con position. Am J Matern Child Nurs. 2010;35(2):71. http://dx.doi.org/10.1097/nmc.0b013e3181cafa36b. 9. Garris BR, Quinlan-Colwell A. Should open visitation be the norm in neonatal intensive care units? Am J Matern Child Nurs. 2010;35(2): 70-71. http://dx.doi.org/10.1097/nmc.0b013e3181cafa36b. 10. Institute for Patient and Family-Centered Care. Advancing familycentered newborn intensive care: a self-assessment inventory. http:// www.ipfcc.org/resources/other/index.html. Published 2004. Accessed February 25, 2013. 11. Institute for Patient and Family-Centered Care. Changing hospital “visiting” policies and practices: supporting family presence and participation. http://www.ipfcc.org/resources/other/index.html. Published 2010. Accessed February 25, 2013.
About the Authors
Laurie A. Lee, DNP(c), APN, NNP-BC, is the neonatal nurse practitioner coordinator at Arkansas Children’s Hospital. She is also the chair for the NICU Family-Centered Developmental Care Council. Melondie Carter, RN, DSN, is a senior faculty member of the University of Alabama-Tuscaloosa, Capstone College of Nursing, DNP program. Sharon B. Stevenson, DNP, APRN, PNP-BC, is the APN Director at Arkansas Children’s Hospital and a PNP in pediatric neurology. H. Allen Harrison, MD, BSN, is the NICU Research Project Manager, Quality Improvement & Neonatology at Arkansas Children’s Hospital. For further information, please contact: Laurie A. Lee, DNP(c), APN, NNP-BC Arkansas Children’s Hospital-NICU #1 Children’s Way Little Rock, AR 72202 E-mail: [email protected]
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ABSTRACT Family presence and participation in care in the NICU is fundamental to the recovery and well-being of the sick neonate and family. However, some NICU visitation policies are not supportive of families. A new visitor-management program was initiated at a local hospital. The program included open visitation for parents and others chosen by parents to be a support during their hospital stay. This qualityimprovement project evaluated if there was any improvement in parents’ perceptions and experiences of family-centered care after the implementation of the new visitor-management program. The NICU parent survey data revealed a modest positive difference in parent responses after the implementation of the program. Keywords: family-centered care practices; visitation guidelines; visitor management; NICU
T
HE FA M ILY CR ISIS R EL ATED TO THE
Accepted for publication November 2013.
birth of an infant who requires hospitalization is a very stressful event. This crisis interrupts parent–infant attachment, which may have lifelong effects.1 Parental roles may change significantly when their infant becomes hospitalized.2 Family-centered care provides support for families who may experience stress, fear, and difficulty with parenting roles when they are in the hospital with their sick newborn infant.1 Parents reported that, when they are not able to help, hold, and care for their infant; protect them from pain; and share the infant with other family members, they experienced symptoms associated with acute stress disorder.3 Encouragement of family presence and participation in caregiving activities can help parents assume their priceless role at their infant’s bedside and help to decrease their stressful feelings. Family presence and involvement is essential to the health, recovery, and well-being of the infant in the NICU. Families, especially parents, can be the best advocates for their infants who have
a wide range of developmental, social, and emotional needs.4 Removing the barriers to family presence and participation is imperative for parents to feel welcomed and valued in an environment that is both unfamiliar and challenging. An essential step in the removal of barriers for families is to examine the unit’s visitation guidelines. These guidelines will provide some important clues to the openness and inclusiveness of the unit to our parents, families, and friends in their greatest time of need. A review of unit guidelines will also indicate the degree to which we are practicing the principles of family-centered care. In a review of the NICU policies regarding the provision of family-centered care, it was determined that the visitation policy was outdated, restrictive, and not welcoming to our parents or their families and friends. In the old policy, parents and grandparents were the only individuals who could spend time with the infant on their own. They were not allowed to enter the nursery until a unit
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secretary called the bedside nurse to determine if they could come to their infant’s bedside. They could not enter the NICU during change-of-shift report times or during other unit activities. Other family members or friends would not be allowed to visit the infant unless one of the parents was present at the bedside. There was no mechanism in place for parents to identify friends and family they would like to have as support systems while their infant was in the NICU. Some parents revealed their concerns about the restrictive visitation practices through the NICU parent survey and in their conversations with the nurses and nurse practitioners. They wanted the individuals in their support network to be able to spend time with their infant when they could not be at the hospital. Parents also wanted to stay with their infant during shift change instead of having to put them back to bed and wait for an hour before reentering the unit to spend time with their infant. This visiting restriction during shift change was especially inconvenient for parents who came to visit their infants after work on their way home. Some parents wanted to be with their infant during procedures to provide comfort and support. Other parents wanted to be present no matter what was going on in the unit. They just wanted to have free access to their infant and to have their family and friends around them during this stressful time. These concerns were brought to our multidisciplinary family-centered care committee for discussion. These concerns were also brought to nursing and physician leaders in the NICU. It was the general consensus of all groups
FIGURE 1
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that we needed to address the needs and requests of our families and provide more open family-friendly visitation in the NICU. A quality-improvement flow diagram was created to help to guide the process and development of the new visitormanagement program. The quality-improvement project aim was to create a family-centered visitor-management program in the NICU. The measure of improvement was defined as a 20 percent improvement between preintervention and postintervention survey scores using the NICU parent survey. Key drivers and processes were identified, and design changes were defined. These details can be seen in Figure 1. A family-centered visitor-management proposal was drafted and presented to several NICU families, the NICU family-centered care committee, NICU nursing and physician leaders, the director of social work services, the vice-president of patient care services, the vice-president of administration, and finally to the chief operating officer of the hospital. The proposal addressed the need to create a family-centered environment in the NICU, which allowed parents to have unrestricted access to their infant, to be able to select family members and friends who will serve as a support network during their hospital stay, and to provide a safe and secure environment for all NICU families and staff members. Support for this initiative was provided, and the proposal was presented to the director of hospital security. After numerous meetings with the hospital security director, staff, and vendors, a visitor-management system was chosen.
Improving family-centered care practices in the NICU.
Improving Family-Centered Care Practices in the NICU
Design Changes
Key Drivers/Processes Project Aim
Aim: Create a familycentered visitormanagement program in the NICU
Measure: There will be a 20% improvement between preintervention survey and postintervention survey scores using The NICU parent survey
1. Review the literature and current NICU policies surrounding visitation in the NICU
2. Talk with families and review NICU parent survey responses regarding familycentered care practices that support family presence
3. Meet with the NICU multidisciplinary familycentered care team, key leaders in the NICU, and the institution to devise a plan supportive of family presence and gather support/funding
a. Change language in NICU visitation policies, orientation to the nursery, and rooming-in guidelines to change perception of the family as visitors
a. Create guidelines that encourage family presence and participation b. Invite parents to identify and utilize a support network during their infant’s hospital stay
a. Pilot a new visitor-management program in the NICU
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The NICU was selected as the unit to serve as a pilot for the hospital visitor-management program. The unit policies were rewritten. Parent and staff materials were updated. Unit secretaries and receptionists were trained how to use the visitormanagement hardware and software. Numerous changes were made in the original “visitation policy” and are reflected in the Family and Friends Guidelines and Orientation in Table 1. All NICU staff members and multidisciplinary team members were informed of the upcoming changes in the visitation policy. Families in the NICU were also informed in person or via a letter of the new guidelines. The NICU visitation policy was retitled, “NICU Family and Friends Guidelines and Orientation.” Parents were given picture badge identification access to their infants 24 hours a day. Parents were able to officially choose family members and friends (a support network) who could come unaccompanied (by parents) to spend time with and care for the hospitalized infant. These individuals were also given picture badges to identify who they were in relation to the infant. Families and staff joined together in this family-centered care venture of open visitation. To try and capture the impact of this new visitormanagement program, data were gleaned from the NICU parent survey regarding parent impressions of family-centered care practices. A retrospective review of survey data was performed three months prior to and after the implementation of the new visitor-management program. It was hoped that the results would show improvement in parents’ perceptions of family-centered care practices in the NICU. NICU staff members agreed, with some trepidation, to support the new open-visitation program for parents and their chosen support network in an effort to improve familycentered care practices. Their reaction and responses to the change in policy were not captured by any formal means. There was some initial resistance to unannounced parental presence at the bedside, which improved over time. The answer to staff’s concern over their lack of control of visitation was to remind them of the importance of this practice to support family-centered care in the NICU. Staff members were also asked to personalize these new practices and visualize their own experiences and needs for family presence when they were a patient in the hospital or had a child or family member in the hospital.
LITERATURE REVIEW
The American Academy of Pediatrics (AAP) issued a policy statement in 2012 surrounding patient and family-centered care and the pediatrician’s role. The policy statement emphasizes that the basis for patient and family-centered care is the recognition that the family is the child’s principle source of strength and support.5 The statement also stresses that patients and families are considered health care team partners, and the perspectives and information shared by families and patients are key to clinical decision making.5
The A AP has identified six core principles of familycentered care. These include the following: 1. Active listening and respect for each child and family member with the acknowledgment of racial, ethnic, cultural, and socioeconomic backgrounds and how they may be used in planning for care delivery. 2. Creating flexibility in policies, procedures, and practices to individualize care. 3. Providing ongoing honest and useful information to patients and families so they can participate in decisions and caregiving. 4. Providing support for the family throughout each stage of the child’s life. 5. Working with families at multiple levels of health care so their contributions can be seen in professional education, policymaking, quality-improvement initiatives, medical research, and family advisory councils. 6. Helping families and children recognize and build on their own strengths, which will build confidence and encourage them to participate in decision making about their own health care.5 The core principles of family-centered care stem from the idea that families can influence the health and well-being of their own family members.6 Because families can have such sway in this area, they need to be supported in their efforts to provide care for the sick family member.6 Some other core principles of family-centered care are described by Johnson. They are (1) treating others with dignity and respect; (2) communication styles and information sharing establish the importance of the individual; (3) families are encouraged to build on their own strengths through activities and experiences that result in greater independence and a feeling of being in control; and (4) care delivery, policymaking, program development, and professional education result from collaboration between patients, families, and providers.6 Johnson also shares four family-centered tenets, which are important in the implementation of family-centered care. They are (1) the constancy of family in the lives of patients, (2) awareness of the many ways that “family” can be defined by patients and families, (3) the importance of buyin from all disciplines and system integration of the family-centered care principles, and (4) extensive patient and family involvement in family-centered care policy and program development.6 NICUs may employ some of the family-centered care tenets and principles in unit policies, procedures, and practices. However, there is always room for growth and improvement in the family-centered care culture of every NICU. Several of the parent needs identified by Cleveland regard parent inclusion in the infant’s care and contact with the infant.2 One of the barriers to the inclusion of parents in caregiving is the actual NICU visitation policy. Gooding and colleagues state that, although progress has been made in expanding visiting hours and encouraging parent presence, many NICUs continue to “close during nursing shift changes and reports, medical rounds, new admissions, emergencies, and neonatal deaths.”4 Gooding and
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TABLE 1
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Family and Friends Guidelines and Orientation
NICU Parents
NICU Siblings
Family and Friends
NICU is open 24 h/d, 7 d/wk. Receptionist will greet parents and explain the NICU Family and Friend’s Guidelines and Orientation to the NICU.
NICU is open for those siblings who are at least 2 y of age for 10–15 minutes at a time so siblings will have a good experience at the bedside.
Family and friends may come with parents from 9 AM –9 PM, 7 d/wk.
Parents choose in writing the grandparents and up to four chosen people with permission to enter NICU without a parent present using the Parental Permission Form.
Complete a Sibling Screening Sheet at reception desk.
Adults may come without parents 24/7 if on the parental permission list.
Family and friends chosen by parents to visit independently may not bring others to visit the infant.
Sibling presence is limited during cold and flu season and also based on unit activity and the attention/behavior of the child.
Children younger than age 14 y are not able to spend time in the NICU unless they are siblings.
Parents may choose not to allow anyone to visit their infant or receive information.
A child life assistant is available to help prepare all siblings for their initial visit. Siblings younger than age 14 y must be supervised at all times by an adult. For the safety of visiting siblings, a request is made that siblings not play on the floor or walk around the nursery when parents are spending time with the infant. Siblings are welcome to spend time in the NICU sibling playroom with a supervising adult or child life specialist. Siblings younger than 18 y of age are not able to spend a night in the Family House.
Because of space limitations, only two people are allowed at the bedside at a time unless the infant is in a private room; up to four people are invited to be at the bedside with the infant and family in a private room.
Check-in Procedure
HIPAA Privacy in the NICU
Infection Control
NICU reception area is designated for check-in and orientation. A welcome NICU Parent Packet is given to parents at time of admission.
For the privacy of others, parents, family, and friends must remain at their own infant’s bedside.
Everyone who visits in the NICU must wash their hands at the scrub sinks at the entry to the nursery or in the area of the infant’s bedside before and after touching the infant or articles at the bedside.
Everyone receives a picture name badge except siblings unless 14 y of age or older. Younger siblings receive an “I am a big brother or big sister” badge.
Nurses may only answer questions about the family’s infant.
Some items are considered “dirty” such as trash can lids, hair, cell phones, and anything that falls on the floor. Hands need to be washed after touching any of these items.
Parents and “chosen” support network will be asked to provide a picture ID which will be used to create a NICU ID badge. They may also be asked to allow a picture to be taken to use for the ID badge if they do not have a current picture ID.
“Chosen” family and friends may receive general information about the infant’s condition during medical team rounds. They may also share in the care of the infant as the infant’s condition permits (such as holding and feeding) per parent preference.
Anyone with signs of illness (elevated temperature, coughing, sneezing, etc.) may not come to the nursery to help prevent the spread of infection to the infants in the NICU.
The NICU ID badge must be worn to enter the nursery and at all times while in the hospital.
To protect the privacy of other infants, pictures may only be taken of one’s own infant. Staff photos may be taken with permission.
Sibling presence is limited during cold and flu season and also based on unit activity and the attention/behavior of the child.
After the badge is received, daily checkin will require everyone to stop at the reception desk to show their badge and use a fingerprint reader for check-in. They will also use the fingerprint reader for check-out.
Toys are welcome at the bedside. However, because of infection control and concerns for infant safety, fuzzy toys or stuffed animals need to remain at home.
Parents and designated family and friends are invited to review the guidelines and orientation with a NICU staff member. They will receive a copy of the guidelines after they have completed their review. (continued)
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Family and Friends Guidelines and Orientation (continued)
Cell Phones/Cameras
NICU Family House (waiting area)
Ronald McDonald House
Cell phones are allowed in the NICU with ringer on vibrate or silent. Cell phones are cleansed with provided wipes when entering the NICU.
A family services assistant is available 7 d/wk from 8 AM to 10 PM.
Located across the street from the hospital for parents
Cell phones may be used for texting; however, for safety reasons, there is no texting when holding infant.
The Family House has chair beds, lockers, and showers for use.
A NICU family services assistant will place parents on a waiting list to stay at Ronald McDonald House.
Use of cell phones for conversations can take place outside of the NICU or in the Family House (waiting area) to help provide a quiet environment for all infants.
As space permits, two sleeping spaces are available to parents/guardians and/ or grandparents; parents who are minors will meet with a social worker to determine their maturity level before they may sleep in the Family House without a grandparent.
NICU family services assistant can also help arrange other lodging as needed.
Families are encouraged to take pictures of their infant(s).
A laundry area and kitchenette is also available in the Family House.
Infant Needs
Additional Information
To promote the healthy growth and development of the infant, voices and noise levels need to be monitored and adjusted while at the bedside to prevent overstimulation of the infant.
Parents are welcomed to call the NICU toll-free number to receive updates and information on their infant. Parents will be given a PIN number to reach the NICU.
Family members are invited to bring socks or booties, clothes, drawings from siblings, pictures of one’s family, and up to two Mylar balloons.
Parents will choose a “code word” to receive information about their infant. If parents choose to share the “code word,” they will be informed that whomever has the “code word” will have access to the infant’s medical information.
colleagues believe that basic components of effective familycentered environments include flexible visiting hours and a culture that makes the entire family feel welcome and valued as “important contributors to the infant’s well-being.”4 The Colorado Consortium of Intensive Care Nurseries (CCICN) analyzed visitation policies of 14 NICUs over a six-year period. The results of the surveys revealed restricted hours for visitation, multiple visitor restrictions including sibling visitation, and authoritarian language in policies that addressed the families’ ability to spend time in the nursery with their infant.7 A consultant helped guide the nurseries to move from “professional-centered family visitation policies to family participation guidelines.”7 At the end of the six-year period, the surveys revealed “more open hours for parents and siblings to be with their baby, less punitive and restrictive language, and a move toward viewing parents as participants in their baby’s care, rather than as visitors.”7 Browne and colleagues believe the creation of family participation guidelines will enhance the family’s ability to care for their infant and help establish critically important parent–infant attachment.7 There is controversy about opening visitation to parents and families in the NICU. According to Krochuk, open visitation or unrestricted access to infants in the NICU should not be the norm.8 Krochuk states that the critical care environment, lack of space around bedsides, the issue of privacy, observations of treatments, and procedures with other
infants are reasons not to permit open visitation.8 Krochuk believes that open visitation may contribute to maternal stress and a feeling of obligation on the part of mothers to be at the bedsides of their infants as much as possible.8 Krochuk proposes that limits should be placed on visitation to help facilitate new mothers’ recovery and self-care behaviors.8 She also states that NICU visitation should be individualized to accommodate the needs of each family.8 Garris, on the other hand, believes that open visitation is a very important part of family-centered care and should be the norm for families whose infants are hospitalized in the NICU.9 Garris states that “open visitation is not only about visiting their baby, but encourages parents and other family members to participate in the care of their ill infants and structure visitation according to their comfort and needs, rather than meeting the needs of the NICU staff.” 9 Garris believes that parents undergo enough stress just with the hospitalization of their newborn infant in the NICU.9 Adding restricted visitation adds more parental stress and anxiety and creates an imposed separation between the parents, family, and their sick infant.9 True advocates and practitioners of family-centered care will have to examine these arguments regarding open visitation in the NICU. They must also be responsible to base their decisions on family-centered care guidelines that have already been established by the AAP and the Institute for
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Patient and Family-Centered Care. A supportive healing environment for sick infants, parents, and family members is one in which there is always a genuine invitation in words and actions for family participation and presence in the NICU.
METHODS
The location for this quality-improvement project is in a 100-bed Level IV NICU that receives, on average, 850 admissions each year. The current average daily census is 70. For several years, the NICU has used a parent survey for ongoing data collection regarding parents’ experiences of family-centered care while their infant is hospitalized in the NICU. All parents who have infants in the NICU for at least two weeks or more are invited to evaluate their NICU stay via the parent survey. The NICU parent survey data are collected through the use of a printed survey tool that incorporates some of the questions from a family-centered newborn intensive care self-assessment inventory. The remainder of the questions in the survey were developed by the NICU family-centered care committee. The original self-assessment inventory tool was published by the Institute of Patient and Family-Centered Care.10 The written introduction of the NICU parent survey informs parents that participation is completely voluntary, and survey responses are anonymous. Parents are also informed that the survey is part of a quality-improvement effort to determine how well the NICU is meeting the needs of our families. They are also told that the information from the survey will be used to educate staff members, develop interventions, and improve practices that will help us meet our families’ needs. The content of the survey includes questions about parents’ first impressions, the NICU environment, caregiving by parents, communication with the health care team, relationships with the health care team, and hospital services. No identifying data are collected. After parents complete the survey, they place the survey in a locked parent survey box at the reception desk in the NICU. Nursing patient care managers retrieve the parent surveys and enter the results into the password-protected NICU parent survey database. The database only contains nonidentified data. The investigator has password-protected access to review the survey results. Because the surveys are only given out once during the infant’s hospital stay, there is no way to perform premeasurements and postmeasurements using the same parent population. A retrospective review of parent survey data was undertaken. The review compared percentages of positive and negative responses in each of the sections of the survey preimplementation and postimplementation of the new visitor-management program. This helped the investigator determine the effects of the program on family-centered care practices in the NICU. All NICU parents were invited to complete voluntary surveys that provided information about their stay in the NICU. Survey responses were anonymous and not linked to any identifying data.
Because this is a retrospective review and no identifying data were collected, risks to the subjects are minimal to nonexistent. There is no direct benefit to the survey participants. The potential benefit of this quality-improvement project is that parents and their support network will feel welcomed and supported by the new family-visitation guidelines and that NICU family-centered care practices will show improvement. Another potential benefit is that parent survey responses may identify other areas that need improvement.
RESULTS
The results of the family-centered care survey are revealed in Figure 2. The second- and fourth-quarter scores reflect the percentage of positive parent responses prior to and after the implementation of the new NICU visitor-management program. Of the 93 surveys obtained during the second and fourth quarter, the overall positive and negative responses for each area were measured. As illustrated, after implementation of the new visitor policies, the positive responses for family first impressions, NICU environment, communication with the health care team, and relationship with the health care team all improved by approximately 5 percent.
DISCUSSION
The parent survey responses indicated that the new visitormanagement program has made a modest positive difference in the parents’ experience and perceptions of family-centered care in the NICU. We did not meet our quality measure goal of 20 percent improvement between preintervention and postintervention NICU parent survey scores. This finding will leave us room for improvement as we continue to work on our family-centered care practices. Some of the questions receiving a high percentage of “always” responses in the fourth quarter were found in four out of five sections of the survey. These sections are family first impressions, communication with the health care team, caring for your infant, and relationships with the health care team. In the fourth quarter, parents rated their feeling of being welcomed in the NICU more highly than those who responded to the parent survey in the second quarter. Parents in the fourth quarter also more highly rated their experience of the NICU as being a caring place. Fourth-quarter parents also believed they received all the information they needed about their infant from hospital staff, were able to understand and read teaching materials, felt supported in breastfeeding, knew their assigned nurse every day, and stated that hospital staff introduced themselves by name each day. These positive responses may be caused in part by the new 24-hour parent access to their infants and more face-to-face interactions with NICU staff members. The parents’ first impressions may have also been influenced by a new reception area and beautiful new Family House waiting room. Fourth-quarter results also revealed a high percentage of “never” responses in two sections of the parent survey. The
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FIGURE 2
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Family-centered care survey results.
Positive Responses Preintervention and Postintervention by Question Type 90.00% 85.00%
% Positive
80.00% 75.00% 70.00% 65.00% 60.00% 55.00% 50.00% FAMILY FIRST IMPRESSIONS
ENVIRONMENT
CARE OF INFANT
COMMUNICATION WITH TEAM
RELATIONSHIP WITH TEAM
2ND QTR POSITIVE
68.57%
75.10%
73.81%
72.65%
61.79%
4TH QTR POSITIVE
73.75%
80.30%
74.71%
77.34%
67.46%
questions were found in the section called caring for your infant and family first impressions. Parents reported that they were never taught how to touch, hold, or be involved in their infant’s care through the use of the “Baby Steps” booklet. The explanation for this result is that the full implementation of the booklet was not complete until after the fourth-quarter survey results were gathered. The survey responses also revealed that parents did not feel their chosen family members or friends were able to hold and care for their infant when they were not able to be in the NICU. It is believed that this negative response may be caused by the newness of the visitor-management procedure as well as incomplete explanations from NICU team members to parents regarding the process of how to build their personal support network for their hospital stay. A major limitation in this quality-improvement project is that we were not able to perform premeasurements and postmeasurements using the same parent populations. Using the same parent populations would have provided more valuable information about parents’ experiences of family-centered care practices before and after the implementation of the new visitor-management program. Another limitation is that we are unable to determine how sick the infants were at the time the parent survey was completed. This may have had a significant effect on the way parents experienced and reported on our family-centered care practices. The location of their infant’s bed, in an open pod versus private room, may have also made a difference in their survey responses. There were several other areas spotlighted for improvement based on parent survey responses. Families indicated that we needed to work on improving teamwork and communication
with families. Several quality-improvement initiatives are under way to address these family concerns. Future study may also include a look at length of stay, acuity, and location of the infant in the NICU because these correlate with parents’ perceptions and experiences of our family-centered care practices.
CONCLUSION
There are several ways nurses can support family presence and participation during the NICU stay. Nurses can skillfully guide families as they learn how to plan and provide for the care of their infant. Nurses can teach families how to work with the health care team and make informed decisions about the provision of quality care for their infants. Nurses can also help families learn how to advocate for their infant throughout the hospital stay, during the discharge process, and in the transition to home or community.11 There are endless ways to promote family presence and participation in caregiving in the NICU. It is so important to try and find the common thread of family centeredness in everything that is said and done for our families. When one is unable to find the common thread, staff members need to stop and humbly ask families for guidance so they will remain on the right path. And as the previously closed doors open to our families, it will be important to remember how critical it is for them to feel welcomed, valued, respected, loved, and cherished throughout the hospital stay. The recovery, health, and well-being of the sick neonate and family receive complete support in a family-centered environment that breeds respect, love, care, and hope for our NICU families.
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REFERENCES 1. Malusky SK. A concept analysis of family-centered care in the NICU. Neonatal Netw. 2005;24(6):25-32. 2. Cleveland LM. Parenting in the neonatal intensive care unit. J Obstet Gynecol Neonatal Nurs. 2008;37:666-691. http://dx.doi.org/10.111/ j.1552-6909.2008.00288.x. 3. Shaw RJ, Deblois T, Ikuta L, Ginzburg K, Fleisher B, Koopman C. Acute stress disorder among parents of infants in the neonatal intensive care nursery. Psychosomatics. 2008;47(3):206-212. http://uams.illiad. oclc.org/illiad/illiad.dll?Action=10&Form=75&value=246245. Accessed November 12, 2012. 4. Gooding JS, Cooper LG, Blaine AI, Franck LS, Howse JL, Berns SD. Family-support and family-centered care in the neonatal intensive care unit: origins, advances, impact. Semin Perinatol. 2011;35(1):20-28. http://dx.doi.org/10.1053/j.semperi.2010.10.004. 5. American Academy of Pediatrics Committee on Hospital Care and Institute for Patient-and Family-Centered Care. Patient-and familycentered care and the pediatrician’s role. Pediatrics. 2012;129(2):394404. http://dx.doi.org/10.1542/peds.2011-3084. 6. Johnson BH. Family-centered care: four decades of progress. Fam Syst Health. 2000;18(2):137-151. 7. Brown JV, Sanchez E, Langlois A, Smith S. From visitation policies to family participation guidelines in the NICU—the experience of the Colorado Consortium of Intensive Care Nurseries. Neonatal Paediatr Child Health Nurs. 2004;7(2):16-23. 8. Krochuk H. Should open visitation be the norm in neonatal intensive care units? Writing for the con position. Am J Matern Child Nurs. 2010;35(2):71. http://dx.doi.org/10.1097/nmc.0b013e3181cafa36b. 9. Garris BR, Quinlan-Colwell A. Should open visitation be the norm in neonatal intensive care units? Am J Matern Child Nurs. 2010;35(2): 70-71. http://dx.doi.org/10.1097/nmc.0b013e3181cafa36b. 10. Institute for Patient and Family-Centered Care. Advancing familycentered newborn intensive care: a self-assessment inventory. http:// www.ipfcc.org/resources/other/index.html. Published 2004. Accessed February 25, 2013. 11. Institute for Patient and Family-Centered Care. Changing hospital “visiting” policies and practices: supporting family presence and participation. http://www.ipfcc.org/resources/other/index.html. Published 2010. Accessed February 25, 2013.
About the Authors
Laurie A. Lee, DNP(c), APN, NNP-BC, is the neonatal nurse practitioner coordinator at Arkansas Children’s Hospital. She is also the chair for the NICU Family-Centered Developmental Care Council. Melondie Carter, RN, DSN, is a senior faculty member of the University of Alabama-Tuscaloosa, Capstone College of Nursing, DNP program. Sharon B. Stevenson, DNP, APRN, PNP-BC, is the APN Director at Arkansas Children’s Hospital and a PNP in pediatric neurology. H. Allen Harrison, MD, BSN, is the NICU Research Project Manager, Quality Improvement & Neonatology at Arkansas Children’s Hospital. For further information, please contact: Laurie A. Lee, DNP(c), APN, NNP-BC Arkansas Children’s Hospital-NICU #1 Children’s Way Little Rock, AR 72202 E-mail: [email protected]
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