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Paul Perez. Latycia Chalisty. Tasya Tobing. CoachArun Mishra. Kenny Auad Pacheco. Dawood Mayar. Ghazwan Salih. Nguyen Xuan Nham. Fatwa Rafiudin. Hammad Gillani. Communication is one of FCCs key tenets such as parents being provided with verbal and written information provided at key points e. On-going communication and information are identified as key features of caregiving requirements [ 18 ] and considered important in terms of: reducing parental stress and anxiety; increasing parental self-confidence and sense of control; improving relationships between parents and their infants and facilitating active participation in staff-parent discussions [ 19 - 21 ].
However, studies have identified how a number of parents do not receive sufficient or appropriate information, e.
Furthermore, whilst communication with parents has been identified as a key component in negotiating roles for the care of their infant, studies show that parents may not know what is expected of them [ 25 ].
One of the most crucial aspects of a change in culture towards a FCC ethos is how staff position themselves in relation to the parents, and their expectations of parental involvement [ 4 , 26 ]. Changes in staff attitudes and behaviours in considering parents as primary caregivers entails a shift of power and role negotiation, which needs active advocacy [ 3 ].
Discrepancies between knowledge and practice have also been indicated; with less experienced [ 27 ] and better educated [ 28 ] staff identified as having a greater awareness, appreciation and application of FCC principles. These GRRs are considered to create prototypical patterns that are crucial to our ability to manage tension, and which subsequently determine our position on the SOC continuum.
According to Antonovsky, experiences of appropriate load balance underload — overload are decisive in determining the sense of manageability. Too much pressure, or the feeling that you do not have the resources e. One of the key elements, emphasized by Antonovsky, in relation to a balance between underload and overload, is active participation in decision-making. The literature suggests that the imbalance between overload and underload and negation of parental involvement in decision-making may be a key barrier to FCC implementation.
Studies report how parents use different strategies to cope with underload and reduce the risk of confrontation or being judged by staff by relinquishing care to staff, mimicking staff in order to conform, or alienating themselves from their infant [ 30 , 31 ]. For socio-economically disadvantaged parents this might be even more pronounced. For example, Flacking et al. Overload is illuminated in research that highlights how some parents have to stay with their infants not out of choice, but because of a lack of or less knowledgeable staff [ 32 ].
Although parental presence during difficult procedures has been identified as important in building parental confidence [ 33 ], parents also express concerns about being involved in procedures that hurt or distress their infant [ 34 ].
From a SOC perspective, high manageability is strongly contingent on high comprehensibility. Therefore, in order to determine whether we have the necessary resources to meet the demands of the stressor, we need to understand what the demands are [ 16 ]. A staff survey undertaken by Petersen et al. Shields and colleagues in Australia [ 37 ], Sweden [ 38 ] and UK [ 39 ] also found incongruence between levels of support needs between staff and parents, with staff considering that parents required more support than they did.
Other issues that impact upon manageability of FCC concern the unit layout and organisation, space, comfort and privacy. Furthermore, the provision of suitable facilities to enable a parent to stay overnight or even to sit comfortably and in close contact with their babies can enhance breastfeeding success [ 42 ]; reduce length of hospital stays [ 43 ] and rehospitalisation rates [ 44 ]; facilitate bonding and promote access to clinical staff [ 14 ] and reduce parental and infant stress levels [ 45 ].
Communal areas to obtain peer support and alleviate loneliness through the sharing of experiences are also identified as beneficial [ 25 ]. From a SOC perspective, formal social and contextual structures need to be in place such as appropriate involvement, access, environment and equipment in order for an underload and overload balance to be maintained [ 16 ].
Whilst progress has been made in NICUs to enable parents unlimited visiting hours, there are still issues in terms of units closing during shift changes, new admissions, and parents asked to leave during medical procedures or ward rounds [ 46 ]. In addition, studies have identified that whilst an environment that supports the presence and involvement of parents increases FCC, such as through a 24 hour visiting policy [ 47 ], staff concerns about parents visiting at their convenience and interrupted work flow need to be addressed [ 3 ].
Meaningfulness relates to the extent to which life makes sense emotionally. This construct concerns our perception that the demands are worthy of investment and that action is desirable [ 16 ]. From a staff perspective, this construct relates to staff engagement with FCC to ensure that parenting goals and needs are attained. In addition, it relates to how meaningful FCC provision is to staff, in terms of ensuring the health and wellbeing of infants and parents.
FCC has developed from attachment theories which emphasize and value the importance of early and continued contact between parents and their infant for bonding, and the development of positive attachment relationships.
However, a large body of research has identified psychological difficulties faced by parents when their infant is hospitalised. Prolonged separation between parents and infants is believed to enhance parental difficulties in caring for their infant with implications for the parent-infant attachment relationship [ 49 ].
Depression, social support, stress, anxiety, self-esteem, maternal well-being and perceptions of motherhood have been found to impact upon mother-infant relationships and interactive behaviours, especially with mothers of preterm infants [ 50 - 52 ]. Meaningfulness can be directly associated with the relational aspects of care; with parent-staff relationships directly impacting on the parent-infant relationships.
Research has identified how mothers of infants admitted to the NICU require assurance-type support [ 18 ] and emotional based care [ 53 ]. Moreover, they can encourage and facilitate contact between parents and their infants and can help to develop parental competence [ 56 - 58 ].
Families who report positive relationships with staff and consider the care to be more family-centred are more satisfied with their overall care [ 59 ]. Furthermore, from a staff perspective, research by Fegran and Helseth [ 56 ] identified how a closer relationship between parents and staff led to clinical staff feeling more committed to take care of the vulnerable infants.
Staff-parent communication therefore needs to be reciprocal and embedded in the creation of trustful bonds [ 25 ]. When professionals set the boundaries for parental participation and parents feel that the infant belongs more to the hospital than to themselves, this can lead to feelings of exclusion, confusion and anxiety [ 29 , 35 , 48 ].
Fenwick, Barclay et al. Paliadelis, Cruickshank, et al. Furthermore, a number of studies have highlighted that when staff perceive parents to be competitors in the care of the infant, they may express a sense of being scrutinized, feeling intimidated by parents and fear of losing power and control [ 29 , 35 , 48 , 63 ].
Indeed, the centrality of meaningfulness to the SOC concept is that even if we are able to understand the stressor and have the resources at our disposal to deal with the situation; if we do not sufficiently care or are motivated towards the outcomes, the situation becomes incomprehensible and we lose command of our resources [ 16 ]. A further point to emphasize is how relationships with parents may lead to negative implications for staff. Their findings emphasized the tension that clinicians may face in balancing between a professional and personal approach.
Close relationships could create situations in which staff felt they were over-stepping the professional boundaries, and therefore attempted to restrict their level of contact with the families [ 56 ]. This study as well as the studies undertaken by Berg and Wigert [ 48 ] revealed that staff often found the interaction with parents more demanding than the provision of clinically based care. Professionals expressed difficulties in engaging with worried parents and instilling trust and hope [ 48 ], with implications for compassion fatigue [ 64 ].
A lack of emotional support for staff has been identified as one of the main barriers for FCC implementation [ 27 ]. This research thereby illuminates how the meaningfulness of relationships with parents can be negated and minimised in practice. In this section, implications for practice, contextualised within the SOC underpinning constructs have been offered. To facilitate Comprehensibility neonatal staff need to provide parents with understandable, unbiased and timely information [ 65 ].
This could involve ongoing, repeated, verbal and written information, starting if possible before the birth, at admission, continued in daily care and as part of discharge procedures. Whilst inclusion of parents within ward rounds has been identified to enhance collaboration amongst team members and enhance parental satisfaction [ 66 ], regular opportunities to talk to and listen to parents may be more effective in promoting shared decision making and resolving unrealistic expectations [ 67 ].
Information, education and support could be delivered via workshops designed for families. Other communication methods that may be beneficial include parental diaries and binders, dedicated phone lines and web-based programmes [ 68 , 69 ]. This requires on-going training and education. Staff should actively listen to parents, to gauge their level of comprehension and to ascertain which messages the parents want to hear.
In the model of FCC described in the POPPY study [ 70 ], there was a strong parental involvement from generating principals to defining indicators for implementation. Promising interventions include engaging communication methods [ 71 ]; targeted communication interventions with care providers [ 72 ]; inclusion of an on-site infant development specialist [ 73 ] and use of web based resources and maps to assist individual care providers and family advisors to provide comprehensive FCC to infants and families [ 74 , 75 ].
Cultural, social and environmental conditions of care need to be provided such as adequate staffing resources, the amount of physical space within the units for parents to be in close contact with their infants, family units encouraging and enabling parents to stay on the unit, facilities for siblings e.
The physical layout of the NICU is crucial, with dedicated family rooms providing space for parents to come to terms with their situation and bond with their infants [ 76 ]. However, parent as well as staff considerations should be included in the design of such units [ 77 , 78 ].
A family support person can help parents to feel less stressed, more informed, confident and prepared for discharge [ 19 ].
Previous research has also suggested how it is important to offer numerous support options for parents, e. As staff operate as the intentional or even unintentional gate-keepers between parents and their infants, the active encouragement of early and repeated physical and close contact is essential to encourage attachment relationships to be formed [ 82 ]. Suitable training and psychosocial support services should be available for staff to help them develop skills and suitable coping mechanisms to effectively deal with the needs of parents and infants in a NICU [ 56 , 84 ].
As research has identified how relationships between staff and parents impacts upon the relationship between parents and infants, the development of interpersonal skills and availability of suitable support are crucial. Ongoing managerial support to ensure that staff are provided with feedback on their performance and roles may also be beneficial.
Indeed as meaningfulness is considered to be the most crucial of the SOC concepts, in terms of how it provides the motivational and cognitive basis for managing and preventing stress [ 16 ], consideration of these issues needs to be at the centre of FCC.
One of the main criticisms of FCC relates to its lack of definition. Whilst policies, guidelines and resources have been developed, there has been less rigorous evidence about FCC as a model of care. This, it is argued, is important for service delivery and care practices to be comprehensible, meaningful and manageable in order to achieve and promote positive well-being and health for all concerned.
None of the authors have any competing interests in undertaking this work. GT conceived the ideas for the paper, and GT and RF were involved in the design and drafting of the initial manuscript.
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