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Promoting Parenting Through Single Family Room Care in the Neonatal Intensive Care Unit
FAMILY DYNAMICS
Promoting Parenting Through Single Family Room Care in the Neonatal Intensive Care Unit Brenda Baker, MN, RNc, CNS and Jacqueline M. McGrath, PhD, RN, FNAP, FAAN
Neonatal intensive care units (NICUs) can trace their traditional large ward style to the 1940s when the focus of design was use of basic monitoring technology and increasing the ease for caregivers to continuously observe and respond to multiple premature infants.1 The growing awareness of infection control, safety, developmentally appropriate care, privacy, and importance of the developing relationship between infant and family has shifted the priorities in NICU design. Today, NICU design addresses the divergent needs of caregivers and families. Caregivers emphasize efficiency, visibility, safety, and access. Families desire privacy, access, and individualized care. Establishing an environment where caregivers feel safe providing care and families feel welcome will create an environment where premature and sick newborns can mature, recover, and ultimately develop a relationship with their caregiver thereby promoting long-term growth and development. Regulatory agencies have established standards that protect privacy, promote infection control practices, and determine space allocation for patient care areas. Although these standards have promoted the concept of single room care, the true benefit of single room care is the opportunity it affords families. Consider for a moment the frightening stark experience a new mother has when she visits her premature or sick infant in the traditional ward-type NICU. The environment can be overwhelming with the constant noise, light, and activity that are daily life in a NICU. Research on the effects of a NICU admission has demonstrated more depression and stress in these mothers, interruption in attachment between mother and infant, increased sense of vulnerability related to the infant's health, and difficulty developing a sense of competence in caring for the infant. The long-term effect of this experience can have long lasting effects on the mother and ultimately growth and development of her child. Beyond survival and growth of the infant, goals of NICU care should include promotion of the family caregiver's experience. In an integrated review of literature, Cleveland2 addressed parenting in the NICU. Six needs of parents were identified— From the Virginia Commonwealth University, Richmond, VA 23298-0510. Address correspondence to Brenda J. Baker, MN, RNc, CNS, Virginia Commonwealth University, P.O. Box 980510, Richmond, VA 23298-0510. E-mail: [email protected]. © 2010 Elsevier Inc. All rights reserved. 1527-3369/1002-0348$36.00/0 doi:10.1053/j.nainr.2010.03.001
accurate information and inclusion in the infant's care, watching over and protecting the infant, contact with the infant, being perceived positively by the nursing staff, individualized care, and a therapeutic relationship with the nursing staff.2 Along with parent needs, 4 nursing behaviors were identified including emotional support, parent empowerment, welcoming and supportive environment, and parent education that included opportunities to practice through guided participation.2 Single family room NICU design provides an environment that allows parents to “watch over their infant, the opportunity to participate in care, time to get to know and care for their infant before discharge, and a welcoming environment to begin parenting.” Single family rooms are more than just private rooms for babies. These rooms have space for families—a bed or sofa that folds into a place to sleep, a chair to rock and hold their infant skin-toskin, a desk for parents to use to read or write, and an area where parents can store their things. The space in these rooms invites families to be there with their infant. Showers nearby and a kitchen are also important. Creating this environment tells families “this place is for you too; we expect and want you to be here with your baby.” In a concept analysis of motherhood in the NICU, 3 critical attributes were identified as significant to the transition to motherhood, each of these attributes are supported by single family room NICU care. Attributes of transition to motherhood in the NICU include time-dependent process, psychoemotional swirling, and hovering around the edge of parenting. A significant antecedent to this concept is mother-infant contact.3 Through single room NICU care, mother and infant have the time, space, and environment that promotes time together, thereby, supporting the transition to motherhood. In addition, factors that influenced the transition to motherhood in this model included uncertainty, lack of opportunities with the infant, and specifically the NICU environment.3 The concept of attachment between mother and infant is described as a reciprocal developmental process that requires proximity, reciprocity, commitment, and is significant in the maternal role attainment process.4 Sensory motor interactions including prolonged visual contact and touch are crucial to establishing maternal infant attachment. Balancing the environment of the NICU and the developing relationship between mother and infant is best achieved by the single family room NICU design. Numerous studies have been published supporting this model. To better describe the experience of parenting in a NICU, a study by Fenwick, 5 identified
categories that explained the intense emotional, cognitive, and worry “work” women experienced as they mothered in the NICU. Categories included just existing, striving to be the baby's mother, learning and playing the game, becoming connected, and struggling to mother.5 This study demonstrated that parenting in the NICU focused primarily on getting to know and connect with the infant. Another significant finding of this research included the vital role the nurse plays in the mother's experience. The mother-nurse relationship can significantly influence how mothers' perceive their relationship to their infant and their competence in caring for the infant.5 Single room NICU care allows mothers time with their infant, and space to care for and get to know their infant. Single room NICU care also allows nurses time to get to know families without interruptions of traditional open NICUs. Every interaction and experience between mother, infant, and nurse contributes to the mother's perception of her ability to care for the infant and ultimately the long-term growth and development of the infant. In a study to determine the effect of single room NICU care vs traditional NICU care on factors that influence motherpreterm infant interaction, 2 groups of mothers were compared. Mothers in group I experienced single room NICU care and group II experienced traditional NICU care with open and flexible visitation. Three months after discharge, mothers were assessed for parental stress, postpartum depression, and perception of vulnerability. Scores in group II were higher for all measures than mothers in group I who experienced single room NICU care, though not statistically significant. This study supports the value of single room NICU care in mothers of premature infants and demonstrates the need for more research in this area.6 Nurses caring for infants in the single room NICU design benefit as well. The NICU is a highly technological, fast-paced, stressful environment. Nurses who work in single room NICUs report higher levels of satisfaction with the work environment, greater satisfaction with patient care they provide, and a higher perception of safety and security in the work environment.7 Nurses are often the main link between mother and infant as mothers' begin forming a relationship that will have lifelong impact on infant development. Satisfaction with the workplace and environment can
72
greatly impact the nurse's experience and therefore the mother's experience. Neonatal nurses are crucial to balancing the environment of the NICU and supporting single family room NICU care. Single family room NICU care that is supportive of parenting includes open accurate communication between families and health care providers, privacy, identification, and support of individual needs of a family and participation in infant care. Single family room NICUs allow for privacy, uninterrupted time for staff nurses to model infant care; opportunities to teach mother's how to read their infant's cues related to feeding, sleep, and play; and time for mother and infant to get to know each other. Mother's who are confident in reading their infant's cues and providing responsive care, are less stressed, experience less depression postpartum, and greater satisfaction in their role as mother, thereby, promoting infant growth and development.4
References 1. Walsh WFM, McCullough KLR, White RDM. Room for improvement: nurses' perceptions of providing care in a single room newborn intensive care setting. Adv Neonatal Care. 2006;6:261-270. 2. Cleveland LM. Parenting in the neonatal intensive care unit. JOGNN: J Obstet Gynecol Neonatal Nurs. 2008;37:666-691. 3. Shin HWTR. The conceptual structure of transition to motherhood in the neonatal intensive care unit. J Adv Nurs. 2007;58:90-98. 4. Johnson Nagorski A. Promoting maternal confidence in the NICU. J Pediatr Health Care. 2008;22:254-257. 5. Fenwick J, Barclay L, Schmied V. Craving closeness: a grounded theory analysis of women's experiences of mothering in the Special Care Nursery. Women Birth. 2008;21:71-85. 6. Erdeve O, Arsan S, Canpolat FE, et al. Does individual room implemented family-centered care contribute to mother-infant interaction in preterm deliveries necessitating neonatal intensive care unit hospitalization? Am J Perinatol. 2009;26:159-164. 7. Stevens DC, Helseth CC, Khan MA, Munson DP, Smith TJ. Neonatal intensive care nursery staff perceive enhanced workplace quality with the single-family room design. J Perinatol. 2010;30:352-358.
VOLUME 10, NUMBER 2, www.nainr.com
Promoting Parenting Through Single Family Room Care in the Neonatal Intensive Care Unit Brenda Baker, MN, RNc, CNS and Jacqueline M. McGrath, PhD, RN, FNAP, FAAN
Neonatal intensive care units (NICUs) can trace their traditional large ward style to the 1940s when the focus of design was use of basic monitoring technology and increasing the ease for caregivers to continuously observe and respond to multiple premature infants.1 The growing awareness of infection control, safety, developmentally appropriate care, privacy, and importance of the developing relationship between infant and family has shifted the priorities in NICU design. Today, NICU design addresses the divergent needs of caregivers and families. Caregivers emphasize efficiency, visibility, safety, and access. Families desire privacy, access, and individualized care. Establishing an environment where caregivers feel safe providing care and families feel welcome will create an environment where premature and sick newborns can mature, recover, and ultimately develop a relationship with their caregiver thereby promoting long-term growth and development. Regulatory agencies have established standards that protect privacy, promote infection control practices, and determine space allocation for patient care areas. Although these standards have promoted the concept of single room care, the true benefit of single room care is the opportunity it affords families. Consider for a moment the frightening stark experience a new mother has when she visits her premature or sick infant in the traditional ward-type NICU. The environment can be overwhelming with the constant noise, light, and activity that are daily life in a NICU. Research on the effects of a NICU admission has demonstrated more depression and stress in these mothers, interruption in attachment between mother and infant, increased sense of vulnerability related to the infant's health, and difficulty developing a sense of competence in caring for the infant. The long-term effect of this experience can have long lasting effects on the mother and ultimately growth and development of her child. Beyond survival and growth of the infant, goals of NICU care should include promotion of the family caregiver's experience. In an integrated review of literature, Cleveland2 addressed parenting in the NICU. Six needs of parents were identified— From the Virginia Commonwealth University, Richmond, VA 23298-0510. Address correspondence to Brenda J. Baker, MN, RNc, CNS, Virginia Commonwealth University, P.O. Box 980510, Richmond, VA 23298-0510. E-mail: [email protected]. © 2010 Elsevier Inc. All rights reserved. 1527-3369/1002-0348$36.00/0 doi:10.1053/j.nainr.2010.03.001
accurate information and inclusion in the infant's care, watching over and protecting the infant, contact with the infant, being perceived positively by the nursing staff, individualized care, and a therapeutic relationship with the nursing staff.2 Along with parent needs, 4 nursing behaviors were identified including emotional support, parent empowerment, welcoming and supportive environment, and parent education that included opportunities to practice through guided participation.2 Single family room NICU design provides an environment that allows parents to “watch over their infant, the opportunity to participate in care, time to get to know and care for their infant before discharge, and a welcoming environment to begin parenting.” Single family rooms are more than just private rooms for babies. These rooms have space for families—a bed or sofa that folds into a place to sleep, a chair to rock and hold their infant skin-toskin, a desk for parents to use to read or write, and an area where parents can store their things. The space in these rooms invites families to be there with their infant. Showers nearby and a kitchen are also important. Creating this environment tells families “this place is for you too; we expect and want you to be here with your baby.” In a concept analysis of motherhood in the NICU, 3 critical attributes were identified as significant to the transition to motherhood, each of these attributes are supported by single family room NICU care. Attributes of transition to motherhood in the NICU include time-dependent process, psychoemotional swirling, and hovering around the edge of parenting. A significant antecedent to this concept is mother-infant contact.3 Through single room NICU care, mother and infant have the time, space, and environment that promotes time together, thereby, supporting the transition to motherhood. In addition, factors that influenced the transition to motherhood in this model included uncertainty, lack of opportunities with the infant, and specifically the NICU environment.3 The concept of attachment between mother and infant is described as a reciprocal developmental process that requires proximity, reciprocity, commitment, and is significant in the maternal role attainment process.4 Sensory motor interactions including prolonged visual contact and touch are crucial to establishing maternal infant attachment. Balancing the environment of the NICU and the developing relationship between mother and infant is best achieved by the single family room NICU design. Numerous studies have been published supporting this model. To better describe the experience of parenting in a NICU, a study by Fenwick, 5 identified
categories that explained the intense emotional, cognitive, and worry “work” women experienced as they mothered in the NICU. Categories included just existing, striving to be the baby's mother, learning and playing the game, becoming connected, and struggling to mother.5 This study demonstrated that parenting in the NICU focused primarily on getting to know and connect with the infant. Another significant finding of this research included the vital role the nurse plays in the mother's experience. The mother-nurse relationship can significantly influence how mothers' perceive their relationship to their infant and their competence in caring for the infant.5 Single room NICU care allows mothers time with their infant, and space to care for and get to know their infant. Single room NICU care also allows nurses time to get to know families without interruptions of traditional open NICUs. Every interaction and experience between mother, infant, and nurse contributes to the mother's perception of her ability to care for the infant and ultimately the long-term growth and development of the infant. In a study to determine the effect of single room NICU care vs traditional NICU care on factors that influence motherpreterm infant interaction, 2 groups of mothers were compared. Mothers in group I experienced single room NICU care and group II experienced traditional NICU care with open and flexible visitation. Three months after discharge, mothers were assessed for parental stress, postpartum depression, and perception of vulnerability. Scores in group II were higher for all measures than mothers in group I who experienced single room NICU care, though not statistically significant. This study supports the value of single room NICU care in mothers of premature infants and demonstrates the need for more research in this area.6 Nurses caring for infants in the single room NICU design benefit as well. The NICU is a highly technological, fast-paced, stressful environment. Nurses who work in single room NICUs report higher levels of satisfaction with the work environment, greater satisfaction with patient care they provide, and a higher perception of safety and security in the work environment.7 Nurses are often the main link between mother and infant as mothers' begin forming a relationship that will have lifelong impact on infant development. Satisfaction with the workplace and environment can
72
greatly impact the nurse's experience and therefore the mother's experience. Neonatal nurses are crucial to balancing the environment of the NICU and supporting single family room NICU care. Single family room NICU care that is supportive of parenting includes open accurate communication between families and health care providers, privacy, identification, and support of individual needs of a family and participation in infant care. Single family room NICUs allow for privacy, uninterrupted time for staff nurses to model infant care; opportunities to teach mother's how to read their infant's cues related to feeding, sleep, and play; and time for mother and infant to get to know each other. Mother's who are confident in reading their infant's cues and providing responsive care, are less stressed, experience less depression postpartum, and greater satisfaction in their role as mother, thereby, promoting infant growth and development.4
References 1. Walsh WFM, McCullough KLR, White RDM. Room for improvement: nurses' perceptions of providing care in a single room newborn intensive care setting. Adv Neonatal Care. 2006;6:261-270. 2. Cleveland LM. Parenting in the neonatal intensive care unit. JOGNN: J Obstet Gynecol Neonatal Nurs. 2008;37:666-691. 3. Shin HWTR. The conceptual structure of transition to motherhood in the neonatal intensive care unit. J Adv Nurs. 2007;58:90-98. 4. Johnson Nagorski A. Promoting maternal confidence in the NICU. J Pediatr Health Care. 2008;22:254-257. 5. Fenwick J, Barclay L, Schmied V. Craving closeness: a grounded theory analysis of women's experiences of mothering in the Special Care Nursery. Women Birth. 2008;21:71-85. 6. Erdeve O, Arsan S, Canpolat FE, et al. Does individual room implemented family-centered care contribute to mother-infant interaction in preterm deliveries necessitating neonatal intensive care unit hospitalization? Am J Perinatol. 2009;26:159-164. 7. Stevens DC, Helseth CC, Khan MA, Munson DP, Smith TJ. Neonatal intensive care nursery staff perceive enhanced workplace quality with the single-family room design. J Perinatol. 2010;30:352-358.
VOLUME 10, NUMBER 2, www.nainr.com