The Challenges of Implementing Family-Centered Care in NICU from the Perspectives of Physicians and Nurses

YJPDN-02021; No of Pages 8 Journal of Pediatric Nursing xxx (xxxx) xxx

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The challenges of implementing family-centered care in NICU from the perspectives of physicians and nurses Jila Mirlashari, BScN, MScN, PhD a,b, Helen Brown, BScN, MScN, PhD c, Fatemeh Khoshnavay Fomani, BScN, MScN, PhD a,⁎, Julie de Salaberry, RN, BSN, MSN(c) d, Tahereh Khanmohamad Zadeh, RN,MSc e, Fatemeh Khoshkhou, BScN, MScN, PhD, RN f a

School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran Women's Health Research, Institute Department of OBGYN, University of British Colombia, Canada c School of Nursing University of British Colombia, Canada d Director, Maternal Newborn Programs, Neonatal Intensive Care and Neonatal Follow Up, BC Women's Hospital + Health Centre, Vancouver, B.C., Canada e Tehran University of Medical Sciences, Markaz Tebi Pediatric Hospital, Iran f High Acuity Care Specialist UBC Hospital, Canada b

a r t i c l e

i n f o

Article history: Received 6 September 2018 Revised 16 June 2019 Accepted 17 June 2019 Available online xxxx Keywords: Qualitative research Family-centered care Neonatal intensive care

a b s t r a c t Purpose: The purpose of this study was to investigate physicians' and nurses' perspectives on the challenges of implementing the FCC in the neonatal intensive care unit. Design and method: The study employed a qualitative design to conduct five focus groups with 25 nurses and 15 physicians (n = 40). All of the nurse participants identified as female; 73% held a bachelor's degree in nursing and 59% had been working as a neonatal nurse for N10 years. Of the physicians, 55% identified as male, 43% held positions as neonatologists and 39% had a minimum of 3 years of experience in neonatal intensive care. Results: Three themes, power imbalance, psychosocial issues, and structural limitation, and related sub-themes were constructed using thematic analyses. Conclusion: The implementation of family-centered care in the neonatal intensive care unit in Iran is shaped by the health care provider, cultural, legal and operational challenges. To optimize effective and sustained implementation, these influential factors must be addressed. Implications: Organizational, managerial and operational changes are required for FCC implementation. Nurses and physicians are well-positioned as leaders and facilitators of family-centered care implementation within the neonatal intensive care unit. © 2019 Elsevier Inc. All rights reserved.

Introduction Globally, family is considered an influential and consistent influence in a newborn's life; consequently, healthcare providers strive to create a supportive environment for family engagement within the neonatal intensive care units(NICU) (Moore, Coker, DuBuisson, Swett, & Edwards, 2003). As Bowlby's original work confirmed, (1953, cited in Harrison, 2010) there are significant emotional, psychological, and developmental consequences of separating mothers and newborns. Studies investigating the negative behavioral impacts associated with parental separation during hospitalization are influencing health care consumerism in ways that are now contributing to improving care for hospitalized children (Ahmann & Johnson, 2000). Since 1955, “child friendly ⁎ Corresponding author. E-mail addresses: [email protected] (J. Mirlashari), [email protected] (H. Brown), [email protected] (F.K. Fomani), [email protected] (J. de Salaberry), [email protected] (F. Khoshkhou).

hospitals” have been promoted by the Citizen Committee on Children of New York City. Within these clinical settings, parents are provided opportunities to spend significant time with their hospitalized children, thereby initiating a shift in the public discourse and expectations about parent-child engagement in neonatal and pediatric care. Family-centered care Family-centered care (FCC), a philosophical and practical approach for promoting parental participation, represents a significant shift for health care providers that involves including parents in the planning and delivery of pediatric and neonatal care. FCC is based on the principles of information sharing, respect and honoring differences, partnership and collaboration, negotiation and care in context of family and community (Ahmann, Abraham, & Johnson, 2004). Within a FCC approach, families are acknowledged to be integral members of the care team and are considered to be primary decision makers for their infants (Moore et al., 2003).

https://doi.org/10.1016/j.pedn.2019.06.013 0882-5963/© 2019 Elsevier Inc. All rights reserved.

Please cite this article as: J. Mirlashari, H. Brown, F.K. Fomani, et al., The challenges of implementing family-centered care in NICU from the perspectives of physicians and ..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.06.013

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Family-centered care is widely accepted as an ideal approach to and standard of care in the NICU (Raiskila et al., 2016). Implementation of FCC has been reported to rely on the knowledge, attitude, and skills of staff, the design of the physical space and the availability of parental support (Gooding et al., 2011). To successfully implement FCC, a shift in health care provider caregiving practices is necessary to promote mutual respect, collaboration, and support for parents. Health care organizational support for staff is also critical as staff adapt their care to promote FCC. Moreover, adequate facilities, innovative and accessible services, along with participation opportunities for families within policy and decision-making process must also be included (Harrison, 2010). Furthermore, implementing FCC in the NICU requires an understanding of the newborns' needs within the context of their families and communities rather than solely focusing on their medical needs (Johnson, 2000). Recognizing the families' strengths and capacities for engagement in newborn care can facilitate their confidence and promotes inclusion in decision-making their infants immediate and future health (Gooding et al., 2011). FCC Implementation and context FCC implementation in the NICUs also supports optimal parentinfant attachment during hospitalization, decreases NICU length of stay and contributes to improving parent and staff experience (Gooding et al., 2011). Despite the known advantages of FCC, challenges and barriers remain that restrict its implementation in the NICU (Raiskila et al., 2016). Studies report that NICU healthcare providers' knowledge and attitudes, the quality and nature of the relationships between nurses and physicians and parents, training in communication skills, and health care policies are key elements of effective implementation and integration of FCC (Hutchfield, 1999; Pediatrics, Medicine, Physicians, & Committee, 2006; Raiskila et al., 2016). Also reported in studies is the role of unit culture for how it facilitates or limits family participation and FCC implementation (Gooding et al., 2011). Considering the socio-contextual and cultural differences among low and highly resourced countries around the world, FCC implementation in the NICU likely faces specific challenges in local contexts. The socio-cultural context also influences parents' perceptions and expectations of involvement in care, as well as the physicians and nurses' attitudes towards parental engagement. For example, Iranian studies reveal that, despite inadequate support from or collaborations with nurses, parents reported the need to stay with their hospitalized children (Heidari, Hasanpour, & Fooladi, 2013). Iranian parents do not view their presence as the central aspect of FCC; they regard it as parental caregiving (Heidari et al., 2013; Shirazi, Sharif, Rakhshan, Pishva, & Jahanpour, 2015). Iranian parents are more interested in providing emotional support for their children than in providing care for them (Aein, Alhani, Mohammadi, & Kazemnejad, 2009). Another study shows differences exist between Iranian nurses and parents about the philosophy practices that constitute FCC. While informative communication is important for Iranian parents, nurses tend to avoid parental involvement in health care decision-making due to their lack of experience and skills (Akbarbeglou, Valizadeh, & ASAD, 2009). In another Iranian study, the NICU environment fostered mothers' participation in newborn care; however, fathers' participation was limited due to traditional attitudes, cultural and religious views about their role in family centered care (Valizadeh et al., 2018). In addition, as nurses work to support FCC within Iranian NICUs, the lack of access to psychologists and social workers to support families has contributed to occupational burnout, work stress, emotional conflicts and added responsibilities. The implementation of FCC in NICUs is not solely a nursing responsibility; health care leaders and policy makers ought to allocate and manage resources for nursing workload for FCC. Psychologists can help nurses to develop and improve their interpersonal relationship skills, patient, and flexibility to provide care based on FCC. Also, social workers' presence at the unit is necessary, because

they are responsible for providing support for the family. Therefore; the lack of psychologists and social workers has contributed to nurses' occupational burnout (Benzies, Shah, Aziz, Lodha, & Misfeldt, 2019; Mirlashari, Valizadeh, Navab, Craig, & Ghorbani, 2018). While parental presence in NICUs is supported by the Iranian Health Ministry, parental engagement in care is limited in NICUs. Where engagement in care does exist, it can be attributed to the pilot implementation of the Newborn Individualized Developmental Care Program (NIDCAP) in four university hospitals. However; in many private and public hospitals, parents are still considered visitors and the reality of FCC is unlikely. Thus, limited knowledge exists about FCC implementation strategies and challenges in Iranian NICUs, particularly from the perspective of nurses and physicians as primary care-givers. The evidence of the benefits of FCC, combined with the Iranian Ministry of Health and Medical Education commitment to improved maternal and neonatal care, makes it timely to investigate the implementation of FCC. This study specifically focused on investigating the facilitators and barriers of FCC implementation within the Iranian context. Using a qualitative design and a content thematic analysis approach, the purpose of the study was to gain understanding of the experiences and perceptions of physicians and nurses working in the NICU about the challenges associated with implementing the FCC in NICUs. The study findings can guide health policy makers, pediatric nurses, and physicians in their collective efforts to implement FCC. The findings have the potential to support FCC by providing insight about efforts to increase the sustainability of FCC in particular NICU contexts. Material and method Study design The study employed a qualitative design and content thematic analysis approach; data were collected during five focus groups, each conducted separately with nurses and physicians. The study's aim was to develop an in-depth understanding of participants̛’ experiences of FCC implementation. Focus groups were used since they allowed for participant engagement and discussion in a group context to expand the discussion (Willis, Green, Daly, Williamson, & Bandyopadhyay, 2009). The focus groups were conducted separately with the nurses and physicians; the rational for this decision was derived from existing studies and the authors' experiences of the hierarchical relationships and unequal power relations among Iranian nurses and physicians. Nurse-physician communication in Iran is limited by the degree of power held by physicians; for example, studies have shown how physicians adopt a sense of authority in their communication with the nurses (Vaismoradi, Salsali, Esmaeilpour, & Cheraghi, 2011; Zakerimoghadam, Ghiyasvandian, & Leili, 2015). Conflict between Iranian physicians and nurses is rooted in physicians' unfamiliarity with the nurses' roles and profession; subsequently, there is limited support of physicians for nursing practice (Vaismoradi et al., 2011). Setting and participants The research was conducted in five hospitals; each site is a main center for providing neonatal care in Tehran. Participants were selected based on their willingness to participate in the study and their direct experiences of providing FCC. All of the nurses and physicians working at NICUs at those five hospitals were invited by email to participate; 40 participants accepted the invitation, (including 25 nurses and 15 physicians). The time and location of the focus groups were arranged based on the preferences of the participants. Participants were selected from five hospitals that shared the same educational systems and standards and were associated with the Tehran University of Medical Sciences. A maximum variation sampling approach was used by including participants with different demographic characteristics (such as educational training and years of experience).

Please cite this article as: J. Mirlashari, H. Brown, F.K. Fomani, et al., The challenges of implementing family-centered care in NICU from the perspectives of physicians and ..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.06.013

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Data collection The data were collected between August and October 2016. Participants were selected from five hospitals with different demographic characteristics. Nurses and physicians of varying ages and years of experience were recruited. Three focus groups with nurses and two focus groups were conducted with physicians. Each group consisted of seven to nine participants and lasted 30 to 50 min. Following an introduction of the research which included a definition of family-centered care, it was emphasized that study aim was to generate diverse perspectives and promote discussion and that group consensus was not being sought. A questionnaire to collect participants̛ socio-demographic information and work experiences in NICUs was given to participants to completion prior to the focus group. The open-ended focus group questions were developed by the researchers through analysis for the FCC literature focused on implementation in NICUs. The researchers used probing questions such as: “can you explain the reasons of your answer” or “would you mind elaborating on your answer and explain more?” The following research questions were asked in the focus groups: • How have you been involved in the family-centered care program in your unit? • What do you think of the family-centered care in our health system? • Are you satisfied with the quality of family-centered care provided in your unit and hospital setting? May I ask you to elaborate on you answer and explain more? • Thinking about your experiences with family-centered care, what could be improved? • Of all the things we discussed, what is the most important? Data analysis The focus groups were analyzed separately for nurses and physicians using thematic approach to content analysis and all finding were integrated. Thematic analysis is a method for identifying, analyzing, and reporting patterns within data (Braun & Clarke, 2006). A five-step process thematic analysis based on Fereday and Muir-Cochran instruction was used in this study (Fereday & Muir-Cochrane, 2006). In the first step, through transcribing the data of each focus group, reading the text, highlighting keywords and phrases, and noting the initial ideas, the researchers worked on achieving familiarity with the text. Subsequently, the coding process began and the data was organized into meaningful groups. Next, codes were grouped into themes and subthemes. The themes were then reviewed again by the researchers checking for coherency and consistency among the extracted codes and the entire data set. To ensure coherency and consistency, researchers reviewed the coded data extracted for each theme to consider whether the support was sufficient for theme and if the themes were internally coherent, individually and collectively. Finally, the themes and their underlying subthemes were defined and classified. To achieve the goal of confirmability, two outside reviewers, a PhD prepared nurse and a psychologist, also coded the transcripts and generated a set of themes and supporting quotations from the transcripts.

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engagement with and immersion in the data over time also enhanced the research rigor. The findings were also validated with several of the participants to ensure the findings were reflective of the experiences described. To enhance the reliability of the data, a complete and continuous recording of the decisions and activities regarding data collection and analysis were presented to the outside researchers. Confirmability refers to the stability of the results in different times and situations, and transferability refers to whether the results of a research are applicable in other situations or to other groups or not (Polit et al., 2006). To achieve confirmability, details of the research and its stages were recorded by the researchers, a report of the research process was prepared, and the validation of the findings by experts were undertaken; these efforts were made to ensure the team were critically reflexive of the influence of any bias influencing the research design, data analysis, interpretation and reporting. To enhance transferability of the results, the researchers provide description and details of the participants' selection and characteristics, and supportive quotations to facilitate the transferability of the findings to other contexts. Ethical approval The study was approved by Tehran University of Medical Sciences Ethics Committee. The certification code number is 93-03-28-27284. Results All nurse participants were female; most of them (73%) had a Bachelor's degree in nursing. The majority of nurses (56%) were between 31 and 35 years old, and 59% of them had been working as a nurse for N10 years. Most of nurse participants (39%) had experience of working in NICU for 1–3 years. The majority of physicians (55%) were male, and 43% of physicians were neonatologists. Among the physicians, 30% were between 41 and 45 years old, and 39% of them had at least three years of work experience in NICU. Three main themes and eight sub-themes emerged from the thematic analyses. The main themes included” power imbalance”, “psycho-social issues”, and “Structural limitations” (Table 1). Power imbalance Two sub-themes emerged from the data related to power imbalance; the medical authority of healthcare professionals and unquestioned physician power. Both nurses and physicians shared their view that they believe parents prefer to place decision making power in the hands of hospital staff, reflecting how parents did not see themselves as qualified to care for or make decisions about their critically ill newborn. The majority of participants believed that the healthcare team had a better understanding of the infants' care needs as compared to the parents; many participants in fact shared that they did not see that parental participation in care was required or even desirable. Additionally, some physician participants expressed concerns regarding the emotional responses of family members engaged in care and subsequently expressed their disagreement with parental involvement.

Rigor To ensure the trustworthiness of the data, Lincoln and Guba's criteria for establishing rigor were used (Lincoln & Guba, 1985). Accordingly, credibility was pursued to improve the accuracy of the findings. Credibility relates to the methodology, credibility of the researcher, and the research philosophy (Patton, 1999). There are several ways to increase the credibility of data; We immersed in the data, sought external review by colleagues and asked some of the volunteer participants to look at the final results of the analysis and emerged themes. So that they ensured us that their views were accurately reflected in our data analysis (Patton, 1999; Polit, Beck, & Hungler, 2006). In addition, deep

Table 1 Summary of themes and sub-themes emerged from thematic analysis. Themes

Sub-themes

Power imbalance

• • • • • • • •

Psycho-social issues

Structural limitations

Belief in medical authority of health professions Traditionally accepted physicians̛ power over Fear High stress atmosphere Unresolved family conflicts Staff disinclination towards fathers' presence in units Policy restriction Organizational limitations

Please cite this article as: J. Mirlashari, H. Brown, F.K. Fomani, et al., The challenges of implementing family-centered care in NICU from the perspectives of physicians and ..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.06.013

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• “Doctors have the total authority. If they don't agree with parent participation, it [familycentered care] cannot happen, even if it [family-centered care] is accepted by nurses and parents”. (Nurse) • “Who is the responsible for the patients? Of course, we are! We are responsible. And consequently we decide whether to involve parents or not. We consider the advantages and disadvantages of their participation. Many parents lose control when facing problems and may harm the baby” (Physician)

The majority of nurses in the study spoke to physician authority enacted over both nurses and families; they identified power relations as the central challenge for implementing FCC. • “Majority of the physicians in our context avoid including parents in the decision making process, because they have the full authority in our health care system and want to make all the decisions themselves. They don't want to share this power with others, especially parents who are not eligible to make medical decision for ill neonates” (Nurse).

Most of participants acknowledged the historical context of physicians' dominance in the NICU, referencing physicians' position of power in Iranian society. For instance, participants mentioned the universal need for and belief in the scientific power of modern medicine for saving human lives and bringing forth life as contributing to their status in Iran. Participants also emphasized how Iranian physicians accumulate social and economic capital that translates to political power and social status that results in the acquisition of senior management positions. “Physicians have the authority in any area because they have the majority of managerial and policy-making positions in our hospitals. Power means authority and authority means they do everything they want. Not only in hospitals, they also have occupied all the administrative and political health related positions of the country” (Nurse). Psycho-social issues Four sub-themes associated with psycho-social issues include fear, high stress atmosphere, unresolved family difficulties, and discouragement of fathers' involvement in care. Participants identified fear as one of most significant barriers to FCC implementation. The participants outlined different types of fear; some spoke to how they thought the families feared their participation would worsen their babies' illness and hasten impending death. The participants indicated how this fear can result in families being incapable of participating in their baby's care, and how patient safety could be subsequently affected. Also expressed was fear that new approaches to care could bring uncertainty considering the more traditional care approaches that were known, accepted and understood by families. Other participants indicated that some parents fear how participating in care could surface social judgment and their own guilt related to having a preterm baby. “In my experience, some parents are concerned about social judgments. They think if they have a preterm baby, they are responsible and feel guilty and that they are being punished for their sins. Therefore, they try to distance themselves from their baby”. [(Physician)] “High stress atmosphere” was another sub-theme emerged from data analysis. Most of the participants discussed the well-established fact that working in high acuity health care settings makes for a challenging workplace. In this study, the nature of neonatal care, needing to be responsive to each families' emotional needs, power relations and conflict with physicians, documentation, paperwork, and challenging relationships with nurse managers were the specific features described as everyday work stressors by the majority of nurses. Physicians in the study also discussed the stressors of their workplace; work overload,

higher than average daily admissions and difficulty working with some physicians who do not advocate for FCC were cited as the most significant sources of stress. Both physicians and nurses complained about workload related to the high volume of paperwork required; this was a significant barrier to the implementation of FCC. Participants also felt obliged to complete many forms and hospital records, resulting in the nurses and physicians feeling overworked and undervalued, which can contribute to a reduced quality of care for newborns and families. “In our healthcare system, paper work is given higher priority than patients. We have too much paperwork. Most of our time is used to complete forms. If we don't spend enough time interacting with our patients, they [managers] will not say anything, but if we miss a record, we will get in trouble”. [(Nurse)] “Unresolved family difficulties”, was another sub-theme. Nurses and physicians both discussed the circumstances that reduced the family's ability to participate in care; such as the distance families live from the hospital, inadequate child care for siblings, living in poverty, and those living with addiction issues. Families with more complex needs require additional support; implementing FCC in these situations is challenging when families may require additional resources, time and support. “Sometimes, we plan to collaborate with parents, but it is not possible. For example, we have a patient whose father is an addict. The parents live in another city and they do not have any accommodation here. They have two other children. Now, how can I expect them to participate in the care?” [(Nurse)] Also evident was the discouragement of fathers' involvement in care; several NICU nurses expressed their discomfort when fathers stay in the unit, specifically referring to inappropriate behavior. It was a concern for nurses and was not mentioned by any physician participant: “We don't feel comfortable whenever fathers stay in the unit for a long time. Because some of them pay attention to us rather than their baby! And this situation violates our privacy” [(Nurse)]

Structural limitations The participants of the current study mentioned different challenges related to the organization structural limitations. Most of these challenges refer the lack of leadership in the area of FCC. Lack of leadership is displayed in lack of philosophical statements about FCC care, lack of in-service education, and lack of organizational infrastructure and clear policies. The sub-theme policy restrictions reflected the lack of structural resources to support parental participation in neonatal care. The participants described the challenges implementing familycentered care as reflecting what is permissible and supported by hospital policy. Without policy support for parental engagement in care, FCC is seen as an optional approach to care rather than as a best practice standard of care. “According to family-centered care, we are authorized to involve parents in decision making and care process. But based on which rules? We have not any policy that governs this practice. We have to uphold and follow policy, not the things that we consider true or think they are true”. [(Physician)] “Organizational limitations” was another sub-theme constructed from the data. The participants indicated how different aspects of the organization function as barriers to implementing family-centered

Please cite this article as: J. Mirlashari, H. Brown, F.K. Fomani, et al., The challenges of implementing family-centered care in NICU from the perspectives of physicians and ..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.06.013

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care. For example, not including principles of family-centered care in hospital philosophy of care, fatigue and stress of NICU staff related to the documentation workload required by the organization, lack of inservice education for family-centered care, and insufficient facilities and organizational infrastructure to support family-centered care implementation. Participants reported that one of the fundamental challenges to implementing family-centered care was the absence of family centered philosophy of care statements in the hospital's strategic plan. Participants believed that the omission of family-centered care language and values in the hospital strategic plan resulted in the exclusion of family-centered care in-service education. A room has been provided for mothers in the hospitals, however there are no facilities existing for fathers who choose to stay close to their baby. Also emphasized was the need for conducting in-service FCC education; currently, there is no FCC-related content in nursing educational curriculum. Discussion This study focused on exploring the experiences of physicians and nurses who were trying to implement an NICU family-centered care program. All the participants affirmed the advantages of FCC but agreed that the implementation barriers reflected in the study findings need to be addressed. Several studies demonstrate the FCC implementation challenges in the Iranian NICU context, such as the pressing issue of resource constraints (Aein et al., 2009; Namnabati, Talakoub, Mohammadizadeh, & Mousaviasl, 2016; Shirazi et al., 2015). For example, although the rooming-in policy is established in all Iranian post-partum wards, there are limited facilities for mothers and fathers in NICU to comfortably stay with their newborns. In many NICUs, there is no space where mothers can stay and rest; consequently, mothers, fathers and other family members are considered visitors rather than integral members of neonatal care team. Currently, there are only a few Iranian NICUs which are piloting the “Newborn Individualized Developmental Care and Assessment Program” (NIDCAP) which shares some of the same goals of FCC. In some units, there may be a room next to the unit where families may not be interrupted; however, only mothers, and not fathers, are able to stay in that space. These rooms are limited for sleeping capacity and do not have bathroom and other facilities. For those units implementing NIDCAP, there is an open-door policy and the units are equipped with chairs beside the newborns̛ incubators. Nonetheless, policy and structural barriers continue to exist for families, staff and stakeholders despite some advancement. In addition, longstanding hierarchical power relations that reflect traditional patriarchal models of care in Iran continue to impact FCC implementation thus necessitating a paradigm shift to more collaborative and empowering approaches (Nasrabadi, Lipson, & Emami, 2004; Parvizy, Mirbazegh, & Ghasemzade Kakroudi, 2016). The findings of this study demonstrate a need for formalized planning and program development at many levels, from the individual to organizational, to establish a FCC approach in Iranian NICUs. Participants in this study acknowledged the extant power imbalances between nurses/physicians and family members. Also, the participants mentioned how these imbalances negatively impact the implementation of family-centered care. Collaboration with the families is necessary at all levels of care, and parental participation in decision-making is considered fundamental (Gooding et al., 2011). Yet, the reality of collaboration is affected by power imbalances located within the patient-health professional relationship (Joseph-Williams, Elwyn, & Edwards, 2014). Quality of care is influenced by the power structures embedded in the nurse-physician relationship and the process of collaboration (Schneider, 2015). Because the power imbalance in the clinical encounter is a key barrier to shared decision making, patients and their families may find it difficult to participate meaningfully in making decisions about their baby's healthcare (Ters & Yima, 2014). Participants also acknowledged the historical clinical dominance of physicians over nurses

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and families, and its effects on parent participation and healthcare teamwork. Although, previous investigations have determined the advantages of teamwork in healthcare; nurses and physicians are often socially positioned in opposition to one another (Price, Doucet, & Hall, 2014). The findings of this study are supported by existing literature. Frosch, May, Rendle, Tietbohl, and Elwyn (2012) demonstrated that even relatively affluent and well-educated patients feel compelled to conform to socially sanctioned roles and defer to physicians during clinical consultations (Frosch et al., 2012). Physicians and nurses in this study believed that parents, for many reasons, preferred to relinquish control to the health professionals. Unquestioned belief in the medical authority of the physicians and nurses, as well as fear of being involved in care, were some of the salient reasons described by the participants. Khajeh, Dehghan Nayeri, Bahramnezhad, and Sadat Hoseini (2017) found that families in Iranian medical contexts are considered to be non-participant visitors; this issue is pervasive as fathers are only allowed to spend one hour a day with their babies in hospital, while mothers are not typically accepted as a medical team member. Furthermore, there is considerable attention paid to documenting efforts aimed at family education in the patient file rather than informing the family about the child's condition and type of treatment. In addition, the nature of family-staff interaction is non-supportive and family members often feel confused and lonely. Some of the family members̛’ questions remain unanswered and they often receive inadequate and inconsistent information (Khajeh et al., 2017). Factors such as a lack of nurse/physician education related to communication style (Al-Hamdan, Banerjee, & Manojlovich, 2018; McCaffrey et al., 2010) and extensive workload (i.e. paperwork) (Alexy & Hutchins, 2006) mean that the nurses deemphasize the importance of spending time with and developing relationships with patients and families; findings that are reflected in our study. These contextual issues restrict family participation in care and decision-making, creating conditions whereby parents prefer to relinquish control to health professionals. Participating in health decisionmaking can be stressful for parent, evoking a sense of responsibility and feeling of “ownership” of their child (Pyke-Grimm, Stewart, Kelly, & Degner, 2006). Providing care for a newborn in the NICU is a stressful experience for parents that has been correlated with parental role alteration, the infant's behavior and appearance, the sight and sounds of the NICU (Shaw et al., 2006), and the impact of the highly specialized NICU environment (Heidari, Hasanpour, & Fooladi, 2012). Relatedly, physicians and nurses have expressed concerns about their ability to provide safe patient care in the presence of distraught family members. This dynamic has been reported as impacting care providers' ability to care for complex patients, especially if they are required to attend to distraught or disruptive family members (Daneman, Macaluso, & Guzzetta, 2003; Duran, Oman, Abel, Koziel, & Szymanski, 2007). Health care providers also report concerns over the traumatic effects of witnessing various procedures and threats to patient safety, a relational dynamic that can prevent parents from fully participating in the care of their baby in the NICU (Duran et al., 2007). Participants also raised concerns that parents could experience more stress if they took on more care giving responsibilities while also relating these concerns to patient safety. These relational dynamics contributing to existing literature relevant to addressing barriers to FCC implementation. Participants in this study described barriers to family engagement in neonatal care related to psycho-social issues. “Fear” was the most significant barrier that affected both parents and NICU staff. “Fear of unknown” by NICU parents has been reported in the literature and is associated with not knowing the baby's long term health outcomes ((Hollywood & Hollywood, 2011) and the fear of social judgment, guilt and punishment (Lee, Norr, & Oh, 2005). Our findings highlight the unwillingness of NICU staff to involve parents in the care due to the uncertainty of the future. Staff expressed a preference in the face of uncertainty to uphold the customary and established biomedical model of care over incorporating a family-centered care approach.

Please cite this article as: J. Mirlashari, H. Brown, F.K. Fomani, et al., The challenges of implementing family-centered care in NICU from the perspectives of physicians and ..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.06.013

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This finding echoes Bamm and Rosenbaum's (2008) study where stigma was a source of fear. Within the Iranian socio-cultural context, perfectionism is highly valued (Heidari et al., 2012) and giving birth to an “imperfect” premature baby may contribute to a sense of shame. Participants in this study highlighted the many challenges that NICU families encounter. These challenges act as barriers to parents̛’ participation in the care of their baby. These include financial pressures, the lack of social supports, disturbance of normal daily life, and barriers related to substance use and addictions. Consistent with our findings, Heidari et al. (2012) reported that unemployment and income loss impacts many NICU families (Heidari et al., 2012). Care giving responsibilities for other children in the family, being absent from work, and the high cost of medical services were also factors that resulted in added financial pressure. The findings of this study reviled the staff members' disinclination towards fathers' long term presence in the NICU. The nurses who participated in the study mentioned that they were uncomfortable when fathers spend long periods of time in the unit, because the fathers paid attention to the nurses and their activities rather than focusing on their baby. A family-centered care philosophy supports the involvement of both parents in the care of their newborn (Feeley, Waitzer, Sherrard, Boisvert, & Zelkowitz, 2013). The role of fathers within the NICU setting is an area of growing interest (Denoual, Dargentas, Roudaut, Balez, & Sizun, 2016; Noergaard et al., 2017). It is also important to consider the complex socio-cultural contexts that exist within the NICU care environment. Difficulties related to father’ presence in the NICU may be rooted in nurses' religious beliefs or the cultural values. All nurse participants in this study were female. Although men practice as nurses in Iran, they typically don't work in NICU as a result of an unwritten hospital policy. Gender difference is a serious issue among Muslims (Ghvamshahidi, 1995), and this social context shapes Iranian nursing. Nurses who identify as female may carry this same bias towards fathers' presence in the unit and attitudinal change has been slow. In contexts where gender segregation has become customary across many different settings, including hospitals, it is expected that people enter the workplace operating from socialized norms and gendered assumptions. These assumptions formulate the basis for how each behavior is interpreted, understood and assigned meaning (Moshtagh, Mirlashari, Rafiey, Azin, & Farnam, 2017). Lack of rules and regulations regarding parent's participation in their baby's care was identified as another challenge to implementing familycentered care in the Iranian NICUs. Clinical practice guidelines that support family participation in Iranian health-care context do not exist. Although Iranian hospital activities are based on a rooming-in model; the presence of fathers is not supported in this approach (TorkZahrani, 2008). As far as structure, most of the NICUs' design is not suitable for implementation of a standard FCC. Guidelines for FCC implementation and design require ongoing research for monitoring and evaluating its results. To successfully implement a family-centered care approach, hospital administrators ought to provide leadership to sanction and hold accountable health care providers, leading a process of policy reform through the development of FCC policies and practice guidelines. In order to fully implement a family-centered care approach a review of policy and organizational authority is required to reform the health policies and provide the resources that are require to implement family-centered care in NICUs (Moore et al., 2003). Participants in this study noted that the family-centered care principles in the hospitals' philosophies of care statements are non-existent. Whereas studies affirm that each institution committed to familycentered care ought to have its values reflected in its philosophy of care (Cooper et al., 2007), our participants cite this reason as one of the barriers to FCC implementation in the Iranian health care system. A hospital's philosophy statement provides a values-based framework for care which is fundamental for health-care practices and best practice standards (Bamm & Rosenbaum, 2008). Therefore, when familycentered care philosophy of care state is non-existent, the structure,

planning and organizational support is lacking within policy and decision to facilitate sufficient resources for FCC implementation. The barriers described related to the lack of in-service education about family-centered care, fatigue and stress of NICU staff due to high volumes of paper work were directly related to health policies and management styles in the hospitals. Shifting the traditional care model to a family-centered care approach is a complex change process; resistance from staff ought to be anticipated and inform implementation planning so that families and staff are empowered to work collaboratively. Another strategy is the use of in-service education to ensure healthcare practitioners̛ knowledge for implementation is sufficient (Griscti & Jacono, 2006) to promote the inclusion of families into the care of infants in the NICU (Nagamatsu, Natori, Yanai, & Horiuchi, 2014). Healthcare providers require sufficient knowledge and effective inservice education to bring new knowledge and innovative FCC into clinical practice. High workloads in hospitals have been for causing stress in workplace (Ayed et al., 2014), poor communications (King et al., 2013), and decreased job satisfaction (Hamid, Malik, Kamran, & Ramzan, 2014); all of these same factors were described as barriers to the FCC implementation in our study. Implications for research and practice According to the study findings, implementation of FCC in Iranian NICUs is challenging because of power imbalance, psychosocial issues, and structural limitations. Nurses and physicians will be required to act as facilitators of change to further enact a family centered approach to care. As part of this shift, nurses and physicians must examine their role and beliefs regarding power, authority and control within the health care encounter and the benefit of family-centered care inservice education on patient and parent outcomes. Families, nurses, and physicians may benefit from consulting services which social workers and psychologist provide. Creating a supportive teamwork atmosphere in the NICU is necessary to resolve psycho-social issues which emerged as a finding in this study. The findings of the current study may also be applicable for hospital management teams focused on quality improvement as significant indicator of excellence in care. Furthermore, educating parents about family-centered care may also contribute to successful implementation. Study limitations The present study has some limitations in that the sample comprised only nurses and physicians. Although many challenges related to the implementation of family-centered care were explored in this study, further studies are needed to identify the parents' points of view to more fully understand the phenomena. Future investigations may benefit from in-depth individual face to face interviews. Further studies are recommended to investigate the dimensions of family-centered care within local contexts that can inform and support a standardized family-centered care model of care in Iran. Conclusion This study has explored nurses and physicians' experiences of implementing FCC in Iranian NICUs and the richness of data has provided solutions for improving the situation for staff and families into the future. The establishment of family-centered care as a new approach in the Iranian context is highly affected by several challenges. Personal, cultural, organizational and managerial factors act as barriers to the implementation of family-centered care. A family centered philosophy of care has not been established within the Iranian health care system and, as result, nurses and physicians face barriers to incorporating family-centered care approaches into everyday practice. Based on our findings, there is a pressing need to shift organizational, management

Please cite this article as: J. Mirlashari, H. Brown, F.K. Fomani, et al., The challenges of implementing family-centered care in NICU from the perspectives of physicians and ..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.06.013

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and operational approaches since successful implementation of FCC by nurses and physician is shaped by the environment in which they work.

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Please cite this article as: J. Mirlashari, H. Brown, F.K. Fomani, et al., The challenges of implementing family-centered care in NICU from the perspectives of physicians and ..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.06.013