Family centred care and family delivered care – What are we talking about?

Identifying outcomes and outcome measures in neonatal family-centered care trials: a systematic review

BACKGROUND

A wide range of outcomes for infants and parents has been reported in clinical trials testing FCC interventions. This systematic review aimed to identify outcomes, outcome measures, and time-points reported in experimental studies testing FCC interventions in neonatal care units.

METHODS

This review included experimental studies investigating FCC interventions in neonatal settings. Database searches were conducted in MEDLINE, EMBASE, CINAHL, Cochrane, PsycINFO, Scopus, JBI, Lilacs, and SciELO, completed in December 2022 and updated in November 2023. Critical appraisal was performed using the JBI checklist for randomized controlled trials, and a narrative synthesis process was used. Outcomes were categorized into the Comet Taxonomy core areas.

RESULTS

The search identified 8787 papers; 42 studies were included in the analysis. Totally, 60 outcomes were identified: 42 infant and 18 parents' outcomes. Outcomes were clustered into 12 domains for infants and five domains for parents and measured by 97 outcome measures. The included studies reported 25 and 27 different time-points for infants and parents, respectively.

CONCLUSION

This review of studies testing FCC interventions identified heterogeneity and inconsistency of outcomes, outcome measures, and time-points measuring the outcomes. Developing a core outcome set for FCC studies is warranted to benchmark the evidence and identify best-practices.

IMPACT

This systematic review identified inconsistency of outcomes, outcome measures, and time-points reported in quantitative studies testing family-centered care interventions in neonatal care settings. The lack of standardized outcomes and outcome measures reported in clinical trials makes it difficult to synthesize data to provide conclusive recommendations. This systematic review will contribute to the development of a core outcome set for research testing family-centered care interventions in neonatal care settings.

A Narrative Review of NICU Implementation of Evidence-Based Early Relational Health Interventions

BACKGROUND

Early relational health (ERH) interventions in the neonatal intensive care unit (NICU) buffer infants from toxic stress effects. Implementation science (IS) can guide successful uptake of evidence-based practice (EBP) ERH interventions. It is unknown if implementors of ERH interventions currently use the resources of IS to improve implementation.

PURPOSE

A narrative review of recent literature on implementation of ERH EBPs was completed to understand (a) which ERH interventions are currently being implemented in NICUs globally, (b) whether clinical implementors of ERH interventions have adopted the resources of IS, (c) existence of implementation gaps, and (d) implementation outcomes of ERH interventions in contemporary literature.

DATA SOURCES

Scopus, PubMed, and CINHAL were searched for original research regarding implementation of dyadic ERH interventions using key words related to IS and ERH.

STUDY SELECTION

For inclusion, ERH EBPs had to have been implemented exclusively in NICU settings, contained data addressing an IS domain, printed in English within the last 5 years. Twenty-four studies met inclusion criteria.

DATA EXTRACTION

Studies were distilled for intervention, IS domains addressed, location, aims, design, sample, and outcomes.

RESULTS

Eleven ERH interventions were described in the literature. Few studies utilized the resources of IS, indicating variable degrees of success in implementation. Discussions of implementation cost were notably missing.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Implementors of ERH interventions appear to be largely unfamiliar with IS resources. More work is needed to reach clinicians with the tools and resources of IS to improve implementation outcomes.

Perceived barriers of family-centred care in neonatal intensive care units: A qualitative study

BACKGROUND

Family-centered care (FCC) approach in neonatal intensive care units (NICUs) has been shown to improve family satisfaction and quality of care. However, several contextual barriers influence its use in NICUs, and these barriers are understudied in Ghana.

AIM

To describe FCC practice in Ghanaian NICUs in order to understand the contextual barriers.

DESIGN

The study employed a descriptive qualitative design.

METHODS

The researchers used a structured interview guide to collect the data in 24 interviews and 12 focus group discussions. We engaged families (n = 42), nurses and midwives (n = 33), and doctors (n = 9) to describe their perspectives on the barriers to FCC in two public tertiary hospital NICUs. The data were mapped, triangulated, and aggregated to inform the findings. Thematic analysis and MAXQDA qualitative software version 2020 were employed to analyse the data. This qualitative study followed the COREQ guidelines and checklist.

RESULTS

Perceived family barriers and perceived facility barriers to FCC were the two main themes. The perceived family barriers include family stress and anxiety, inadequate information sharing and education, culture and religion. The perceived facility barriers are inadequate space and logistics, workload and inadequate staff, restricted entry, and negative staff attitudes.

CONCLUSION

The findings of this study shed light on the barriers to FCC practice in neonatal care in Ghanaian NICUs. Family stress and anxiety, a lack of information sharing, cultures and religious beliefs, NICU workload and staffing shortages, restrictions on family entry into NICUs, and staff attitudes towards families are all contextual barriers to FCC practice.

RELEVANCE TO CLINICAL PRACTICE

Health facility managers and NICU staff may consider addressing these barriers to implement FCC in the NICU in order to enhance family satisfaction and quality neonatal care. The design of future NICUs should consider family comfort zones and subunits to accommodate families and their sick infants for optimal health care outcomes. The development of communication models and guidelines for respectful NICU care may aid in integrating families into ICUs and promoting quality health care outcomes.

Mothers' involvement in providing care for their hospitalised sick newborns in Kenya: a focused ethnographic account

INTRODUCTION

There is growing evidence that parental participation in the care of small and sick newborns benefits both babies and parents. While studies have investigated the roles that mothers play in newborn units in high income contexts (HIC), there is little exploration of how contextual factors interplay to influence the ways in which mothers participate in the care of their small and sick newborn babies in very resource constrained settings such as those found in many countries in sub-Saharan Africa.

METHODS

Ethnographic methods (observations, informal conversations and formal interviews) were used to collect data during 627 h of fieldwork between March 2017 and August 2018 in the neonatal units of one government and one faith-based hospital in Kenya. Data were analysed using a modified grounded theory approach.

RESULTS

There were marked differences between the hospitals in the participation by mothers in the care of their sick newborn babies. The timing and types of caring task that the mothers undertook were shaped by the structural, economic and social context of the hospitals. In the resource constrained government funded hospital, the immediate informal and unplanned delegation of care to mothers was routine. In the faith-based hospital mothers were initially separated from their babies and introduced to bathing and diaper change tasks slowly under the close supervision of nurses. In both hospitals appropriate breast-feeding support was lacking, and the needs of the mothers were largely ignored.

CONCLUSION

In highly resource constrained hospitals with low nurse to baby ratios, mothers are required to provide primary and some specialised care to their sick newborns with little information or support on how undertake the necessary tasks. In better resourced hospital settings, most caring tasks are initially performed by nurses leaving mothers feeling powerless and worried about their capacity to care for their babies after discharge. Interventions need to focus on how to better equip hospitals and nurses to support mothers in caring for their sick newborns, promoting family centred care.

The influence of nurse characteristics on practice skills and attitudes towards working with families in critical care: A regression analysis

OBJECTIVES

The study aimed to identify nurse characteristics that influence their self-perceived practice skills in working with families and their attitudes towards engaging families in adult and neonatal intensive care units.

RESEARCH METHODOLOGY/DESIGN

Secondary data analysis using a descriptive, cross-sectional design.

SETTING

An online survey was completed by 256 nurses from six adult intensive (73% response rate) and two neonatal intensive and one intermediate care unit (27% response rate) in a Swiss, university affiliated hospital.

MAIN OUTCOME MEASURES

Nurses' self-perceived practice skills in working with families were assessed with the "Family Nursing Practice Scale". Attitudes towards families were measured with the "Families' Importance in Nursing Care - Nurses' Attitudes Scale". Data were analysed with multiple linear regression models.

RESULTS

Prior education in family nursing significantly influenced nurses' self-perceived practice skills in working with families. Nurses' clinical speciality had a significant influence on their attitudes towards overall, and on the subscale "family as a burden". Neonatal intensive care nurses showed more open attitudes towards families overall, but perceived family more often as a burden than nurses in adult intensive care. Nurses' perceived skills and attitudes in family engagement significantly influenced each other.

CONCLUSION

The results suggest that nurses' prior education in family nursing and clinical speciality determine their ability to work with and engage families in critical care. Our study suggests that integration of family nursing engagement practices in critical care requires educational implementation strategies combined with culture change efforts.

'With every fibre of their being': Perspectives of healthcare professionals caring for children with non-malignant life-limiting conditions

BACKGROUND

Children with non-malignant life-limiting conditions (NMLLCs) constitute the largest proportion of children requiring palliative care. In part, due to technological advances, growing numbers of such children are experiencing improved survival. Care is mostly provided at home by the family, with significant professional input at different points in the child's life trajectory. This study explored the experience of healthcare professionals caring for this cohort of children.

METHODS

A qualitative descriptive study design using single-occasion one-to-one semi-structured interviews collected data from 12 healthcare professionals' including nurses, social workers and doctors. Data were analysed using thematic analysis.

RESULTS

The findings highlighted the unfailing determination and dedication of healthcare professionals who provided care despite challenges with what seemed like 'with every fibre of their being'. Three key themes marked such strength and commitment; those were 'being there', 'being focused' and 'being strong'. 'Being there' explicitly highlighted expert care that was individualized and responsive to the child and family's unique needs. The provision of such care was often threatened and potentially compromised by the intricacies and challenges associated with children's palliative care (CPC) and service provision. 'Being focused' captured the sense that the healthcare professionals remained entirely focused on providing expert care despite these challenges. 'Being strong' epitomized the personal and professional impact on healthcare professionals who are working in this area and the manner in which they sustain themselves in 'being focused' and in 'being there'.

CONCLUSIONS

The healthcare professionals demonstrated their unwavering commitment to deliver quality care required by children and families, however against a background of issues relating to organizational constraints. The findings have implications for education/service providers such as the need for specific palliative care education at both pre-registration level and continuing professional development.

Parents' needs and perceived gaps in communication with healthcare professionals in the neonatal (intensive) care unit: A qualitative interview study

OBJECTIVE

To explore parents' needs and perceived gaps concerning communication with healthcare professionals during their preterm infants' admission to the neonatal (intensive) care unit (NICU) after birth.

METHODS

Semi-structured, retrospective interviews with 20 parents of preterm infants (March 2020), admitted to a Dutch NICU (level 2-4) minimally one week, one to five years prior. The interview guide was developed using Epstein and Street's Framework for Patient-Centered Communication. Online interviews were audio-taped and transcribed verbatim. Deductive and inductive thematic analysis was performed by two independent coders.

RESULTS

Communication needs and gaps emerged across four main functions of NICU communication: Building/maintaining relationships, exchanging information, (sharing) decision-making, and enabling parent self-management. Communication gaps included: lack of supportive physician communication, disregard of parents' views and agreements, missing communication about decisions, and the absence of written (discharge) information.

CONCLUSION

This study improves our understanding and conceptualization of adequate NICU communication by revealing persisting gaps in parent-provider interaction. Also, this study provides a steppingstone for further integration of parents as equal partners in neonatal care and communication.

PRACTICE IMPLICATIONS

The results are relevant to practitioners in the field of neonatal and pediatric care, providing suggestions for tangible improvements in NICU care in the Netherlands and beyond.

When can I hold my baby? An audit of time to first cuddle for preterm babies (<32 weeks) pre introduction and post introduction of a Family-Integrated Care model

AIM

The audit examined time to first cuddle between preterm babies (born < 32 weeks) and their parent pre- and post-introduction of a family-integrated care model. Secondary outcomes included time to full feeds and length of neonatal intensive care stay.

BACKGROUND

Parental separation due to neonatal intensive care unit admission is known to negatively affect parental and baby wellbeing.

DESIGN

A "before-after" design compared outcomes for babies admitted pre- (2015) and post (2018)-implementation of the model in a Western Australian neonatal intensive care unit.

METHODS

A retrospective medical record audit included babies from two gestational age groups in 2015 and 2018, born ≤27 + 6 weeks and 28-31 + 6 weeks. SQUIRE checklist guided reporting of the audit.

RESULTS

One hundred fifty-three babies were included in the audit, 79 from 2015 (≤27 + 6 weeks n = 39 and 28-31 + 6 weeks n = 40) and 74 from 2018 (≤27 + 6 weeks n = 35 and 28-31 + 6 weeks n = 39). Babies in both years were born at similar median gestational ages with comparable birthweights. Babies born ≤27 + 6 weeks in 2018 were cuddled earlier (median = 141 h old) compared with those in 2015 (median = 157 h old). Median time to reach full feeds decreased and was significant in the ≤27 + 6-week group: 288 h (12 days) in 2015 to 207.5 h (8.6 days) in 2018. Length of stay was longer for the ≤27 + 6-week gestation 2018 group (median = 64 days) and 28-31 + 6-week gestation 2018 group (median = 22 days).

CONCLUSION

Family-integrated care models may decrease the time to first cuddle and full feeds. Further research on outcomes such as breastfeeding, infant weight gain and length of stay can extend existing knowledge.

RELEVANCE TO CLINICAL PRACTICE

Family-integrated care models may offer benefits to families of hospitalised preterm babies and investigating barriers to its implementation and creation of solutions to overcome barriers warrants attention.

Nursing competencies for family-centred care in the hospital setting: A multinational Q-methodology study

AIM

to identify: (1) nursing competencies for FCC in a hospital setting; and (2) to explore perspectives on these competencies among Dutch and Australian professionals including lecturers, researchers, Registered Nurses and policy makers.

DESIGN

A multinational cross-sectional study using Q-methodology.

METHODS

First, an integrative review was carried out to identify known competencies regarding FCC and to develop the Q-set (search up to July 2018). Second, purposive sampling was used to ensure stakeholder involvement. Third, participants sorted the Q-set using a web-based system between May and August 2019. Lastly, the data were analysed using a by-person factor analysis. The commentaries on the five highest and lowest ranked competencies were thematically analysed.

RESULTS

The integrative review identified 43 articles from which 72 competencies were identified. In total 69 participants completed the Q-sorting. We extracted two factors with an explained variance of 24%. The low explained variance hampered labelling. Based on a post-hoc qualitative analysis, four themes emerged from the competencies that were considered most important, namely: (a) believed preconditions for FCC; (b) promote a partnership between nurses, patients and families; (c) be a basic element of nursing; and (d) represent a necessary positive attitude and strong beliefs of the added value of FCC. Three themes appeared from the competencies that were considered least important because they: (a) were not considered a specific nursing competency; (b) demand a multidisciplinary approach; or (c) require that patients and families take own responsibility.

CONCLUSIONS

Among healthcare professionals, there is substantial disagreement on which nursing competencies are deemed most important for FCC.

IMPACT

Our set of competencies can be used to guide education and evaluate practicing nurses in hospitals. These findings are valuable to consider different views on FCC before implementation of new FCC interventions into nursing practice.

The Scope of Family-Centred Care Practices, and the Facilitators and Barriers to Implementation of Family-Centred Care for Hospitalised Children and their Families in Developing Countries: An Integrative Review

PROBLEM

Limited knowledge exists regarding the scope practices and implementation from developing countries. This integrative review aims to report research on the scope of FCC practices, facilitators and barriers to the FCC implementation for hospitalised children and their families in developing countries.

ELIGIBILITY CRITERIA

Qualitative, quantitative, mixed-method studies, reports, systematic reviews and integrative reviews reporting implementation, barriers and facilitators of FCC, published in English between 2008 and 2018, from developing countries were evaluated. Joanna Briggs Institute Appraisal Tools were used for methodological assessment.

SAMPLE

Eleven studies from developing countries met the inclusion criteria. Four studies were randomised controlled trials, five were cross-sectional, one was a quasi-experimental while one was a qualitative study.

RESULTS

The scope of FCC research focuses on information sharing, family participation, and respect and dignity and FCC implementation focuses on practices and perceptions, measurement and impact of FCC. Both personal and health system facilitators and barriers exist but their influence on FCC implementation is limited. Research on needs of families and hospitalised children is also limited.

CONCLUSION

FCC practice and research are still in infancy stage in developing countries. There is limited understanding on scope of FCC practices, the needs of parents and children, and the influence of facilitators and barriers.

IMPLICATIONS

The limited findings reported in this review support the need for international collaboration to FCC to critique FCC research and integrate it with other philosophies such as child and family centred care and child centred care as is the case in some developed countries.

Developing a Family-Centered Care Model in the Neonatal Intensive Care Unit (NICU): A New Vision to Manage Healthcare

Family-centered care (FCC) currently takes a greater role in health care, due to the increasing empowerment parents experience. Within neonatal intensive care units (NICUs), family participation has an impact on the humanized care of the preterm newborn (PN). This integrative review conducted according to Whittemore and Knafl investigated current knowledge of the FCC model and its application in PN care in specific units. The data were collected from PubMed, Cochrane, CINHAL, Scopus, and Google Scholar. A total of 45 articles were used, of which 13 were selected which met inclusion criteria. Their methodological quality was evaluated using the mixed method appraisal tool (MMAT), and after they were analyzed and grouped into four thematic blocks: (1) parental participation; (2) health parental training; (3) benefits of family empowerment; and (4) humanized care. The results revealed that FCCs promote the integration of health equipment and family. In addition, parents become the primary caregivers. The benefits of the family–PN binomial enable an earlier hospital discharge. Humanized care involves an ethical approach, improving health care. Changes are still needed by health managers to adapt health services to the needs of the family and PNs.

'Sometimes you are forced to play God…': a qualitative study of healthcare worker experiences of using continuous positive airway pressure in newborn care in Kenya

​OBJECTIVE: To explore the experiences of using continuous positive airway pressure (CPAP) in newborn care among healthcare workers in Kenya, and to identify factors that would promote successful scale-up. ​DESIGN AND SETTING: A qualitative study using key informant interviews and focus group discussions, based at secondary and tertiary level hospitals in Kenya. ​PARTICIPANTS: Healthcare workers in the newborn units providing CPAP. ​PRIMARY AND SECONDARY OUTCOME MEASURE: Facilitators and barriers of CPAP use in newborn care in Kenya. ​RESULTS: 16 key informant interviews and 15 focus group discussions were conducted across 19 hospitals from September 2017 to February 2018. Main barriers reported were: (1) inadequate infrastructure to support the effective delivery of CPAP, (2) shortage of skilled staff rendering it difficult for the available staff to initiate or monitor infants on CPAP and (3) inadequate knowledge and training of staff that inhibited the safe care of infants on CPAP. Key facilitators reported were positive patient outcomes after CPAP use that increased staff confidence and partnership with caregivers in the management of newborns on CPAP. Healthcare workers in private/mission hospitals had more positive experiences of using CPAP in newborn care as the relevant support and infrastructure were available. ​CONCLUSION: CPAP use in newborn care is valued by healthcare workers in Kenya. However, we identified key challenges that threaten its safe use and sustainability. Further scale-up of CPAP in newborn care should ensure that staff members have ready access to optimal training on CPAP and that there are enough resources and infrastructure to support its use. ETHICS: This study was approved through the appropriate ethics committees in Kenya and the UK (see in text) with written informed consent for each participant.

Parents' and Staff Perceptions of Parental Needs During a Child's Hospital Admission: An Australian Study

PURPOSE

This study aimed to identify parents' and staff perceptions of parents' needs during a hospital admission and relationships between needs, socio-demographic and clinical variables.

DESIGN AND METHODS

A cross-sectional descriptive design. Forty-six parents whose child received care and 17 staff who worked within a paediatric ward at a secondary hospital in Western Australia completed the Needs of Parents' Questionnaire in 2016.

RESULTS

Parent and staff perceptions of the importance of needs were congruent but differences arose between parents and staff on whether these needs were met and needed. Parents were more likely to rate needs as less important, more met and more needed than staff members. Demographic characteristics significantly influenced parents' and staff perceptions of parents' needs in hospital.

CONCLUSIONS

Staff need to acknowledge that the parent and child's hospital trajectory and demographical characteristics can influence the parent and child's needs in hospital. For family centred healthcare delivery to be effective, care delivery needs to be aligned to what parents and children state their needs are at that time.

PRACTICE IMPLICATIONS

This study has highlighted that future international collaborative research networks are needed to critique the concepts and clinical implications of FCC from a broader lens and recipients, deliverers and providers of healthcare need to be cognisance of contemporary FCC literature.