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Enhancing person-centred communication in NICU: A comparative thematic

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 RESEARCH
doi: 10.1111/nicc.12062

Enhancing person-centred
communication in NICU:
a comparative thematic analysis
Janne Weis, Vibeke Zoffmann and Ingrid Egerod

ABSTRACT
Aims and objectives: Aims of this article were (a) to explore how parents of premature infants experience guided family-centred care
(GFCC), and (b) to compare how parents receiving GFCC versus standard care (SC) describe nurse-parent communication in the neonatal
intensive care unit.
Background: Family-centred care (FCC) is acknowledged as fundamental to supporting parents of premature infants, and communication
is central to this practice. Accordingly, nurses need good communication skills. GFCC is an intervention developed to improve nurse-parent
communication in the neonatal intensive care unit. This intervention helps nurses to realize person-centred communication as an approach to
optimize contemporary practice.
Design: Our qualitative study had a descriptive and comparative design using semi-structured interviews to explore the parent’s experience
of GFCC.
Methods: We conducted 10 dyad interviews with parents (n = 20) and two individual interviews with mothers of premature infants (n = 2).
Parents in the intervention group versus SC group were 13 versus 9. Thematic analysis was applied.
Findings: GFCC was generally experienced as supportive. Three interrelated themes were identified that illustrated how the intervention
helped parents cope as persons, parents and couples: (a) discovering and expressing emotions, (b) reaching a deeper level of communication,
and (c) obtaining mutual understanding. In contrast, SC communication was more superficial and less structured. Factors such as inaccessibility
of nurses, inability to ask for assistance and parent popularity impaired successful communication.
Conclusion and implications for practice: Our study suggested that compared to SC, GFCC provided structured delivery of
supportive communication between nurses and parents of premature infants. The intervention promoted the discovery of the parents’
individual preferences and concerns, which enabled more focused communication, and set the stage for better nurse-parent and parent-parent
understanding. We recommend GFCC as a method to improve communication in the neonatal intensive care unit.
Key words: Communication • Family-centred care • Intervention • Neonatal intensive care unit • Neonatal nursing • Parental stress

INTRODUCTION health care professionals. Family-centred care (FCC)

Premature birth and admission to the neonatal
intensive care unit (NICU) are stressful events for
newly fledged parents. During admission the parents
must rely on close collaboration with a variety of
Authors: J Weis, MScN PhD Student CCRN, Clinical Nursing Researcher,
Department of Neonatology, Copenhagen University Hospital
Rigshospitalet, Copenhagen, Denmark; V Zoffmann, MPH PhD RN, Senior
Researcher, Steno Diabetes Centre A/S, Gentofte, Denmark; I Egerod, MSN
PhD RN, Professor, Health and Medical Sciences and Trauma Centre,
Copenhagen University Hospital Rigshospitalet, University of Copenhagen,
Copenhagen, Denmark
Address for correspondence: J Weis, Clinical Nursing Researcher,
Department of Neonatology, Copenhagen University Hospital
Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
E-mail: janne.weis@regionh.dk
is acknowledged as the fundamental for delivery of
quality care in NICU, where the family is cared for as
a unit (Latour et al., 2005; Shields et al., 2007; Coughlin
et al., 2009). Communication is a key feature of FCC.
To follow the principles of FCC, nurses need good
communication skills. In this article, we explore guided
family-centred care (GFCC) as a way to realize person-
centred communication in NICU.
BACKGROUND
Parental stress related to hospitalization of the
premature infant has been evaluated in a number
of studies (Miles et al., 1992; Davis et al., 2003;
Dudek-Shriber, 2004; Carter et al., 2005; Singer et al.,
2010). The sources of stress are many, including

© 2013 British Association of Critical Care Nurses 1

 Communication in NICU
the bewilderment of premature birth, the unfamiliar
environment and alterations in the parental role.
Parental stress has been associated with development
of depression, acute stress disorder and post-traumatic
stress disorder (Elgar et al., 2004; Shaw et al., 2006, 2009;
Vigod et al., 2010; Feeley et al., 2011). These potentially
detrimental outcomes threaten to impair early parent-
infant interaction and normal child development.
According to FCC principles, care should be
delivered in a manner that helps parents manage
their stress and supports their parenting. Care
tailored to the individual needs of the patient and
family should support them in discovering their
own strengths (Gooding et al., 2011). Therefore,
methods for negotiating personal care plans with
the parents are important for achieving successful
parent empowerment (Aston et al., 2006). Parent-
nurse collaboration is a cornerstone of FCC and
parents emphasize a collaborative relationship with
the nurses as the most important factor for a positive
NICU experience (Reis et al., 2010; Gooding et al.,
2011). Empathy, information sharing and support of
parenting efforts are nursing behaviours consistent
with collaborative relationships (Cleveland, 2008).
Nurses generally acknowledge FCC as fundamental
to nurse-parent collaboration, but sometimes compli-
ance rather than empowerment is obtained (Coyne
et al., 2011; Gooding et al., 2011). To bridge the gap
between philosophies of care and contemporary
nursing behaviour, nurses need guidance, education
and organizational support (Coyne, 2008; Coyne et al.,
2011; Trajkovski et al., 2012).
Person-centred communication is associated with
positive outcomes and sets the stage for FCC (Ammen-
torp et al., 2011). We conceived guided family-centred
care (GFCC) as a new intervention aimed at enhancing
person-centred communication between nurses and
the parents of premature infants in NICU, and we
hypothesized that GFCC would promote FCC philoso-
phy by improving communication and reducing stress.
Aims
The aims of our study were (a) to explore how parents
of premature infants experience GFCC and (b) to
compare how parents receiving GFCC versus standard
care (SC) describe nurse-parent communication in the
NICU.
METHODS
Design
This study is part of a larger study into the effect
of GFCC on parental stress. A preliminary step
(phase I) included development of a framework
2 © 2013 British Association of Critical Care Nurses
for implementing GFCC in NICU. We assessed
intervention fidelity of 25 NICU nurses prior to testing
the effect of GFCC on parental stress in a randomized
clinical trial (phase II). This study (phase III) was
conducted after the intervention to explore the parent
perspective and to assess the clinical significance of the
intervention.
Setting
The study was conducted in a level III NICU at a
university referral hospital with approximately 1200
NICU-admissions per year, of which infants born
before 34th gestational week (target group) comprised
approximately 300 admissions. The unit was organized
in three subunits with separate management and
approximately 40 nurses in each. Double occupancy
rooms were available to most families with a bed for
one parent beside the infant.
Intervention
GFCC is a structured nurse-parent communication
intervention superimposed on SC in NICU. The inter-
vention is intended to minimize stress and encour-
age empowerment through planned and structured
dialogue. Parents prepare for dialogues by com-
pleting reflection sheets designed to support nurse-
parent communication. The development of GFCC
was inspired by Guided Self-Determination (GSD),
which was originally designed to overcome barriers
to empowerment in complex diabetes care (Zoffmann
and Lauritzen, 2006; Zoffmann and Kirkevold, 2012).
NICU trajectories evolve through three phases
related to infant condition, parental concerns and
nurse-parent relationships: (1) The acute critical phase,
(2) the stabilizing phase and (3) the discharge
phase (Pehrsson and Sandén-Eriksson, 2002; Fegran
et al., 2008a). We developed an intervention package
consisting of four ‘reflection sheets’ designed to
guide the dialogues during the three NICU phases
(online appendix A–E). The fundamentals of GFCC
supplementing SC are presented in Table 1.
GFCC-certified nurses were allocated as primary
nurse to families in both study arms strictly adhering to
SC or GFCC. This design allowed for ascribing possible
effects and parent experiences to the intervention rather
than nurse qualifications (Weis et al., 2013). Other
staff nurses cared for the family when the primary
nurse was unavailable. No adverse effects of GFCC on
parental stress were identified during the feasibility
study (unpublished data).
Participants
The participants in this study were parents (n = 22)
of premature infants in NICU: 10 couples and two

Table 1 Standard care and guided family-centred care
Standard care
Parental presence in NICU
Unrestricted visiting with a bed for one parent next to the infant
Continuity of care
• Primary care nursing
• One primary nurse and 4-5 contact nurses allocated to each family in NICU
• Infant and family care plans primarily worked out by the nurses based on
their perceptions of infant and family needs
Communication
• Scheduled admission dialogue with parents.
• Dialogues focus on unit checklists using interview guide to help identifying
parent concerns and preferences.
• Ad hoc day-to-day communication when attending to infant care and
treatment.
• Nursing focus on information and parent teaching
NICU, Neonatal intensive care unit; GFCC, Guided Family-Centred Care.
mothers of whom one was a single parent and the
other participated without her partner. The main
study consisted of 74 parents in the intervention
group and 60 in the SC group. We selected 13
parents from the intervention group and 9 from
the SC group to participate in post-intervention
interviews. A majority represented the intervention
group to increase material for exploring experiences
of receiving GFCC. Purposeful sampling was applied
to capture rich evidence elucidating the research topic
(Sandelowski, 2000). Aiming for maximum variation
among participating families, differences in infant
gestational age, length of stay, single- or multipara,
and parent demographics guided the sampling. Parent
ethnicity is not usually recorded in Denmark.
Data collection
Using a qualitative design, we conducted 12 semi-
structured interviews with 22 parents of premature
infants. Interviews provided thick description of
themes relating to the aims of our study and saturation
was reached when emerging themes reiterated during
the final interviews (Denzin and Lincoln, 2005;
Ponterotto, 2006). The interviews were conducted 3–6
months after NICU discharge (November 2011 to
April 2012). The lapse in time allowed for exploring
parents’ long-term retention of meaning related to
communication. The interviews took place at the
informants’ homes at a time of their choice. One
couple opted for being interviewed at the hospital.
Ten interviews were dyads of mothers and fathers
and two were individual interviews with mothers.
All interviews were conducted by the first author
(J. W.) lasting 1–2 h. A semi-structured interview
© 2013 British Association of Critical Care Nurses
Communication in NICU
Guided family-centred care
Scheduled dialogues (1 h)
• Admission Dialogue in acute critical phase
• Values Clarification Dialogue in stabilizing phase
• Discharge or Transfer Dialogue in discharge phase
Follow-up dialogues
• Dialogues as needed in NICU (20 min.)
GFCC components
• Invitation and collaboration dialogue to initiate the process
• Completion of reflection sheets prior to dialogue
• Completion of Negotiated Plan during each dialogue
GFCC communication techniques
• Mirroring
• Active listening
• Values clarifying responses
Table 2 Interview guide
– How did you experience admission with your baby to the neonatal
intensive care unit?
– How did you experience becoming parents under these circumstances?
– Please, tell me about a dialogue you had with a nurse (what comes to
mind)?
– How was this dialogue significant to you?
– How did you experience communication with the nurse?
– How were you informed on subjects of relevance to your baby’s
condition and your own concerns and preferences?
– How did dialogues with the nurses influence your sense of being parents
and a family?
– How did you experience your influence on your baby’s care and
treatment?
– How did you experience being listened to?
– How were negotiated plans and agreements respected?
– How did you experience life as a family after discharge?
– How did were you prepared for post-discharge parenting?
– How did you manage the situation as a couple?
guide was developed based on the GFCC framework
(Table 2). Parent’s statements were verified throughout
the interviews by iterative questioning.
Data analysis
The interviews were transcribed verbatim and
rechecked by the first author (J. W.). Data were anal-
ysed inductively using thematic analysis as presented
by Braun and Clarke (2006), who describe six phases
of analysis: (1) familiarization with the data reading
the transcripts, searching for meanings and patterns
and producing an initial list of interesting evidence;
(2) generating initial codes by organizing the identified
features into meaningful groups; (3) interpreting and
3
 Communication in NICU
sorting related codes into potential themes; (4) review-
ing the themes for coherent pattern within themes
and clear distinctions between themes, and creating a
thematic map; (5) defining and naming the themes con-
cisely by identifying the essence, i.e. what is interesting
about the data extracts and why; and (6) producing the
report providing a concise, coherent and interesting
story about the data within and across themes that
augment the research question (Braun and Clarke,
2006; Rennie, 2012).
The first author (J. W.) analysed all interviews gen-
erating initial codes before discussing these with the
co-authors. All authors participated in sorting and
interpreting codes into potential themes. This process
was guided by the intervention framework selecting
codes and themes fitting into a thematic map on
effective nurse-parent communication, hence, apply-
ing a more deductive approach during steps 3 and
4. Throughout all phases, constant checking of data
extracts, codes and themes against each other and
the whole data set was performed. The analysis was
conducted using the computer software NVivo9 (QSR
international) providing an audit trail. We pursued
credibility by investigator triangulation, transferability
by obtaining thick description, dependability by pro-
viding quotes from informants and confirmability by
describing the processes of sampling, data collection,
and analysis.
Ethical considerations
The study was registered at Controlled Trials Ltd.
(ISRCTN 82244704), and approval was obtained
from the Danish Data Protection Agency (2009-41-
3665). Furthermore, the study was reported to the
National Committee on Health Research Ethics (H-
A-2009_FSP21). Unit approval was obtained from
the directors of nursing and medicine. Parents
participating in the intervention study were informed
verbally and in writing of the aims of the study, and
written consent was obtained. The participants were
assured of confidentiality and concealment of identity.
FINDINGS
Thirteen parents from the intervention group and nine
parents from the SC group agreed to participate. Mean
age (range) of mothers was 31 years (24–38), and
fathers 33 years (26–38); NICU stay was 41 d (6–86) and
infant gestational age was 28 + 4 weeks (24 + 0 weeks
to 33 + 1 weeks). Parent characteristics are shown in
Table 3.
GFCC was generally experienced as supportive
in relieving parental stress during NICU admission.
Structured dialogues reinforced the development of
4 © 2013 British Association of Critical Care Nurses
relationships between parents and nurses that sus-
tained parental managing. Three interrelated themes
were identified illustrating how parents coped as per-
sons, parents and couples through empowering rela-
tionships with nurses: (1) discovering and expressing
emotions, (2) reaching a deeper level of communica-
tion, and (3) obtaining mutual understanding. Table
4 presents the three themes with constituting quotes.
Interrelatedness of the themes is illustrated in Figure
1. In the following, the experiences of GFCC parents
will be described. In addition, GFCC parent experi-
ences will be compared and contrasted to SC parent
experiences. We denote GFCC mothers and fathers as
M1 + F1 to M7 + F7 and the SC mothers and fathers as
M8 + F8 to M12 + F12 when quoting from interviews.
Discovering and expressing emotions
Becoming a parent of a prematurely born infant in an
intensive care setting was perceived as a chaotic and
stressful experience. Infant condition and appearance,
parent-infant interaction, environment and emotional
strain were reported as exhausting and stressful.
Adding to parental distress was their ambivalent
emotional response to the unpredictable life situation,
which was experienced as a gallery of ever-changing
feelings ranging from sadness and anxiety to relief
and joy. In preparation for parent-nurse dialogues,
the parents in the intervention group were asked
to complete the semi-structured reflection sheets. As
the parents started to reflect on their reactions, they
discovered their unrecognized emotional responses,
and the insight gave them a sense of relief. One mother
explained:
‘[Using reflection sheets] helped us put into words
some of the things we actually felt inside. It felt good
to express some of the chaos, because it is chaotic
having a baby born that early.’ (GFCC-M7)
Scheduling was important, because dialogues might
otherwise have been cancelled or postponed in the
complexity of daily life in the unit. Scheduling also
helped the parents to prioritize completing the sheets.
A father said:
‘And that they were scheduled, the dialogues, I think
that was very important . . . but you have to find the
time for it, and, of course, make [reflection sheets] a
priority . . . ’ (GFCC-F5)
A few parents, mainly fathers, were initially reluctant
to complete the reflection sheets because they failed to
understand the point. Getting started, however, most
 Communication in NICU

Table 3 Parent characteristics

Study Mother Father Infant gestation Transfer to

Parent Number allocation (age, years) (age, years) (age, weeks) NICU stay (d) local hospital

M1 + F1 GFCC 32 37 26 + 0 61 No
M2 + F2 GFCC 28 31 29 + 6 36 No
M3 + F3 GFCC 38 38 24 + 4 triplets 73 Yes
M4 + F4 GFCC 24 30 30 + 4 6 Yes
M5 + F5 GFCC 36 38 33 + 0 twins 23 No
M6 GFCC 31 30 + 4 14 Yes
M7 + F7 GFCC 26 26 29 + 3 6 Yes
M8 + F8 SC 38 35 24 + 0 29 Yes
M9 + F9 SC 38 32 25 + 2 86 Yes
M10 + F10 SC 26 32 33 + 1 15 No
M11 SC 32 31 + 4 86 No
M12 + F12 SC 27 28 24 + 3 triplets 59 Yes

GFCC, Guided Family-Centred Care; SC, standard care; M, mother; F, father.

Figure 1 Process of interrelated themes in guided family-centred care communication.

fathers found it meaningful. One father in particular
still found it difficult to put his experiences into writing.
He did, however, appreciate having the structured dia-
logues, and he acknowledged the reflection sheets as
an excellent tool for his wife, who found them helpful.
In summary, the parents in the intervention group
found scheduled dialogues and reflection sheets
meaningful and supportive. No parents in the SC group
reported comparable support.
Reaching a deeper level of communication
Communication with the nurses was identified as
central to supporting parental managing. Finding the
energy to focus on their own needs was difficult, as
parents generally were putting their needs aside to
focus on the infant. GFCC, however, set the stage for
exploring the needs of the parents. One mother said:
‘It just meant a lot to me to talk things through.
Because you can always discuss things with family
and friends, but a nurse knows something about it
and also knows about stuff that might bother you.’
(GFCC-M4)
Although parents and nurses communicated as
usual during daily care, the scheduled dialogues
helped the parents manage by taking the discussions to
a deeper level. Moreover, having reflected in advance
helped the parents remember and bring up important
issues that might not otherwise have surfaced. One
father explained:
‘We talked all the time [in the unit], but that was
different. We discussed subjects at a deeper level [in
the dialogues]. Yes, we discussed totally different
subjects than in the unit everyday life.’ (GFCC-F5)
Most SC parents felt supported when nurses asked
about their emotional, physical and psychosocial well-
being during infant care. Parents managed by asking
questions and discussing personal issues if the nurse
stayed on after attending to the infant. Communication,
however, appeared more superficial, and nurses failed
to explore parent preferences as an integral part of
problem solving. The parents had to find just the
right moment to discuss personal matters with the
nurse, which made them dependent on the accessibility

© 2013 British Association of Critical Care Nurses 5

 Communication in NICU

Table 4 Three main themes and examples of constituting parent quotes

Identified themes GFCC parent quotes SC parent quotes

Discovering and expressing
emotions
Reaching a deeper level of
communication
Obtaining mutual understanding
GFCC-M1: You are so engaged with your baby – you are
not dealing with your own situation. I’m so glad we
were invited to participate and had the chance to fill in
these sheets.
GFCC-F3: I think it was good having to write something
down. But it was not easy.
GFCC-M5: It was a bit difficult finding the time but it felt
good going through the sentences having time to
reflect on the situation because things were often fast
paced in the unit. It was nice having these questions to
help me think things over.
GFCC-F5: It was quite fun – we filled in the sheets
separately. I experienced this as an aid to cope also as
a couple.
GFCC-F3: It worked well being updated during these
dialogues in private. I think it would have been difficult
If we only had communicated with the nurses on
random basis.
GFCC-M4: It just meant a lot to me to talk things
through. Because you can always discuss things with
family and friends, but a nurse knows something about
it and also knows about stuff that might bother you.
GFCC-F5: We talked all the time [in the unit], but that
was different. We discussed subjects at a deeper level
[in the dialogues].Yes; we discussed totally different
things than in the unit everyday life.
GFCC-F5: [Having filled in reflection sheets] made it
easier to remember stuff in the dialogue – in contrast
to just discussing matters in the dialogue thoughts had
been made in advance.
GFCC-M1: She met us where we were and listened to us.
But she also prepared us for the next step.
GFCC-F2: It was a process for us to talk through the
questions in the reflection sheets. I think we were
totally unaware of some of our differences . . . we
knew there were differences in our views, but being
forced to reflect on it, put it into words, that was what
I experienced as most valuable afterwards.
GFCC-M4: Having agreed with the nurse that we would
be involved as much as possible and that no initiatives
would be made unless we were present made us feel
respected as parents.
GFCC-M5: [Having explicit plans] made it possible for me
to keep control of the situation – also knowing when
it would be okay for me to go for a walk as this was
important to my own recovery.
SC-M10: We were not involved in decision-making and
we didn’t quite understand why we had to do one
thing rather than another. It was not until after
discharge I realized that we actually needed more
explanations.
SC-F12: There are many things you need to think about
as a parent – also practical things such as the right
way to arrange sick leave and you just don’t have the
energy. Maybe you don’t realize this until you come
home and then it may be too late.
SC-F8: They also did it [nurses stayed and talked] because
they liked us. It was obvious that it was not everybody
. . . there were some [parents] they had quite different
relationships with.
SC-F10: You may get into a negative spiral when you are
overwhelmed by all the general information available.
We needed somebody who sat down and discussed
our personal situation.
SC-M11: I don’t think [our infant] was considered ‘‘an
interesting case’’ . . . It was so hard because different
nurses cared for [our infant] all the time even though
the contact nurses were on duty.
SC-M12: We felt so insecure. We needed more
information on a regular basis – we really wanted to
be involved but we had no idea of what we could do.
SC-M9: I found it [skin-to -skin contact with my baby] so
distressing . . . I could not see that it benefitted her.
When she was most fragile I found it far less
distressing to sit and hold her in the incubator but I
never discussed my thoughts with the nurses
SC-M11: I don’t think I actually told anybody that I was
very upset. I just made a big deal out of saying how I
wanted things to be done and what I wanted to do
myself.
SC-F12: Everything was so chaotic – we did not ask for
more information – we just existed . . . and tried to
tag along.
SC-M12: Our ways of handling the situation sort of
collided. Where I need openness and honesty, [my
husband] is more the type who withdraws. And that
made it very difficult.

of the nurses and privacy in the room. In fact, SC . . . there were some [parents] they had quite different
parents perceived that the development of a supportive relationships with . . . we could not help noticing
relationship depended on the popularity of the parents. that.’ (SC-F8)

‘They also did it [stayed and talked] because they In both study groups, the parents experienced a lack
liked us. It was obvious that it was not everybody of continuity due to staffing logistics. Each family had

6 © 2013 British Association of Critical Care Nurses


to collaborate with ever changing nurses with different
approaches to care. GFCC parents experienced disre-
gard for negotiated plans when new nurses took over,
adding to their distress and lack of self-confidence.
‘Of course it was difficult to communicate with the
staff because there were so many nurses. I think we
met them all. They were all very nice, but it was
difficult because each nurse had their own idea of who
we were, and what we should do, and what they had
to do.’ (GFCC-M1)
In summary, the GFCC parents perceived the
scheduled dialogues as empowering because of
consistency and undivided attention from the nurse.
Without this structure in SC, successful communication
was impaired by factors such as inaccessible nurses,
preferences of nurses (parent popularity) and inability
of parents to ask for assistance. Compared to SC, GFCC
promoted successful person-centred communication,
although the logistics of staffing failed to provide
optimal nursing continuity in the unit.
Obtaining mutual understanding
Parents perceived GFCC as supportive for them as
individuals and as a couple. The NICU environment
and lack of sleep were not conducive to feelings of
being a couple and a family. Couples risked relational
disruption, and mutual understanding was threatened
by the unfamiliar situation. In both groups, mothers
were distressed by the interrupted pregnancy and
feelings of guilt for not being able to carry the infant to
full term. GFCC did not alleviate the sense of guilt, but
helped the mothers explore their feelings, which was
the first step to recovery. A SC mother expressed her
feeling of guilt:
‘And now I become sad, I don’t know why. I was
terrified of losing her . . . I felt so guilty for not being
able to carry her longer. I felt that it was my fault she
now lay there with all the tubes.’ (SC-M8)
Some fathers immediately felt fatherly pride,
whereas others first experienced emotions of father-
hood at discharge from the NICU. These emotions
were uncovered by GFCC and aided parents in under-
standing each other’s views and perceptions.
‘It was very exciting to hear his side of the story.
We didn’t talk a lot to each other, unfortunately. We
were just so busy with it all . . . one of us in bed
asleep, the other holding the baby, and it just felt
so demanding being here [in the unit]. There wasn’t
© 2013 British Association of Critical Care Nurses
Communication in NICU
room for conversation. So it has been great to have
these [GFCC dialogues].’ (GFCC-M1)
During the GFCC dialogues, the parents were able
to acknowledge each other’s ways of dealing with
the situation, which promoted mutual understanding
and consideration for each other. The dialogues also
created an opportunity to complete the story when the
parents had different experiences, e.g. when the father
accompanied the infant to the unit while the mother
remained in the delivery room. The parents did not
believe that they would have found the time and the
resources for this type of communication without the
structure of GFCC.
‘It was a process for us to talk through the questions in
the reflection sheets. I think we were totally unaware
of some of our differences . . . we knew there were
differences in our perceptions, but being forced to
reflect on it, put it into words, that was what I
experienced as most valuable afterwards.’ (GFCC-F2)
Mutual understanding between nurses and parents
was facilitated by GFCC as nurses gained insight
into the lives of the parents. Knowing the parents
enabled the nurses to tailor information, work out
personal plans and anticipate the next step, which
nurtured meaningful nurse-parent relationships. A
father commented:
‘When discussing issues where we were personally
or emotionally involved, she just listened. Otherwise,
she was active [explaining or commenting] when a
professional or unit issue was discussed.’ (GFCC-F5)
Having personal plans explicitly worked out during
the dialogues provided transparency to unit life
routines, and this transparency helped the parents to
look out for themselves while still managing other
activities. The dialogues enabled parents to give
feedback on their experiences of daily care and to
discuss potential conflicts encountered in collaboration
with other nurses. Some parents found it difficult to
muster the strength to confront nurses who had been
insensitive to them or their infant. One mother said:
‘I can still feel that I am a bit annoyed, but then I’m
so glad that I had that talk with the [primary care]
nurse . . . ’(GFCC-M1)
SC parents appreciated when nurses asked personal
questions during daily care. This behaviour was
perceived as an attempt by the nurses to get to know the
7
 Communication in NICU
parents. But if a SC couple experienced disagreement
among themselves, they could not automatically expect
professional assistance to sort things out. One mother
explained:
‘Our ways of handling the situation sort of collided.
Where I need openness and honesty, [my husband] is
more the type who withdraws. And that made it very
difficult.’ (SC-M12)
In summary, GFCC offered more structured assis-
tance than SC, because the method guided parent-
parent and parent-nurse communication to gain
mutual understanding. Shared decisions were made
in care plans on issues that might have been ignored in
SC. GFCC promoted individualized care, whereas SC
was more random.
DISCUSSION
The aim of our study was to explore how parents of
premature infants experienced GFCC, and, to compare
how parents receiving GFCC versus SC described
nurse-parent communication in the NICU. We identi-
fied three interrelated themes illustrating how GFCC
helped parents to cope as persons, parents and couples
through empowering relationships with nurses. We
found that the discovery and expression of emotions
enabled a deeper level of communication, which, in
turn, set the stage for mutual understanding between
parent and nurse and between parents (Figure 1).
Delivery of efficient patient and FCC is an
important issue in political health care agendas, where
responding to parents’ concerns and preferences is
regarded as a tenet of high quality care (Latour et al.,
2005; Latour et al., 2010). Communication strategies
to empower parents have been identified as crucial
to the improvement of health care services towards
supporting parents’ well-being. However, only few
attempts have been made to realize FCC in practice
(Mikkelsen et al., 2011). To this end, GFCC is a
suitable method causing transformation of ad hoc
communication in SC into an empowering family-
centred approach.
The sample in our study was small, and we did
not attempt to make generalizations but, rather, to
describe the mechanisms in our intervention that were
successful. The study supported our hypothesis that
GFCC would pave the way for FCC. Structured person-
centred communication facilitated empowerment and
contributed to the transformation of the prevailing
agenda of compliance toward empowerment (Petersen
et al., 2004; Shields et al., 2007; Cleveland, 2008; Gooding
et al., 2011).
8 © 2013 British Association of Critical Care Nurses
Preparing for dialogues by using reflection sheets
set the stage for parental reflection by putting
experiences into writing. Hence, the time between
scheduled dialogues was fruitful in supporting
parental managing by guiding to express their
emotions, concerns and preferences (Zoffmann and
Kirkevold, 2012). Being prepared, parents became
more active during the dialogues, and parent-nurse
collaboration profited from information sharing, which
promoted shared decisions on daily care. Accordingly,
family empowerment was supported through the
increased insight of the parents (Patterson, 2002).
Mutuality is a core value of FCC acknowledging that
both nurses’ professional knowledge and parents’ pri-
vate knowledge and family values are important (Cor-
lett and Twycross, 2006; Mikkelsen and Frederiksen,
2011). Our study demonstrated how scheduling and
structuring dialogues stimulated successful communi-
cation enabling parents and nurse to share knowledge
and experiences. ‘Reaching a deeper level of communi-
cation’ is a metaphor reflecting the increased meaning-
fulness of the conversation. According to the social pen-
etration theory, interpersonal communication moves
from relatively shallow levels to more intimate ones
as relationships develop (Altman and Taylor 1973).
As such, GFCC promoted this process, though main-
taining a professional relationship. Conversely, SC
communication was described as more superficial. The
availability and preferences of the nurses influenced
nurse-parent communication. Apparently, haphazard
communication might be experienced as ineffective by
the parents (Wigert et al., 2006; Cone, 2007).
A medical-technical focus often prevails in NICU
where the agenda of advanced medical procedures
dominate a caring perspective (Griffin, 2006). The
consequences of postponing vital medical-technical
actions are known to be potentially fatal, whereas
the consequences of ignoring the establishment of
relationships with parents might not be as evident
(Wigert et al., 2008). GFCC holds the potential to change
nurses’ attitudes by providing insight into the worlds
of the parents paving the way for shared decision-
making.
The mothers and fathers in our study had varying
perceptions of situations and appreciated using
reflection sheets as a vehicle to gain insight into
each other’s experiences. Other studies have provided
similar examples of perceptual differences between
parents (Jackson et al., 2003; Fegran et al., 2008b;
Matricardi et al., 2013). Perceptual differences increase
the risk of conflict, which could ultimately lead
to broken families (Benzies et al., 2004). When
gaining insight into conflicting perceptions, the
involved parties had a chance to negotiate care-plan
 Communication in NICU

decisions addressing the priorities of both parents.
Most importantly, the nurse was a catalyst in
situations where the parents needed to understand
each other.
The exchange of views, experiences and knowledge
was central to helping the family as a unit. Educational-
behavioural interventions as the COPE program
(Creating Opportunities for Parent Empowerment)
has been shown to reduce parental stress through
knowledge of infant cues, knowing what to expect, and
increased parental engagement in care (Melnyk et al.,
2006). In our study, nurses prepared parents for the
next step which promoted transparency in the NICU
trajectory and helped parents regain control. GFCC
demonstrated potential to uncover disagreements
and enable mutuality, thus preventing paternalism
or consumerism (Zoffmann and Kirkevold, 2012).
Addressing emotions and individual coping strategies,
GFCC may work well in combination with educational-
behavioural interventions (Howland, 2007).
There are some limitations to our study. Our
preconceptions of the usefulness of the intervention
could potentially have influenced the interview process
and subsequent analysis. However, we faithfully
explored and reported both negative and positive
parent experiences. Interviewing parents together
might have negatively influenced their openness,
although parents gave the impression of being open
and also helped each other to remember when
reflecting on experiences. Investigator triangulation
increased the trustworthiness of our study. We
included direct quotes from most of the informants
to document our findings and to improve credibility.
Transferability is inherently challenging in qualitative
studies, but we assume that some results are
transferable to other NICUs with a similar context.
CONCLUSION
Our study suggests that GFCC provides structured
delivery of supportive communication between nurses
and parents of premature infants in the NICU. This
intervention promoted the discovery and expression
of emotions, which enabled a deeper level of
communication and set the stage for mutual nurse-
parent and parent-parent understanding. Moreover,
this type of intervention has the potential to increase
sensitivity to person-specific issues within the nursing
profession by guiding the acknowledgment of parents’
personal experiences in critical or stable courses. Not
all issues concerning daily collaboration were resolved
through the use of GFCC, but as more nurses are
trained, we believe that confidence will increase in
promoting family-centred care and empowerment
philosophies.
ACKNOWLEDGEMENTS
We thank families, study nurses and managers who
participated in this study. This study was sup-
ported by grants from the Lundbeck Foundation
FP/30/2009, FP/13/2010, FP/55/2011, Novonordisk
Foundation November 2011, Danish Nurses Orga-
nization Research Foundation March 2011, Aase
and Ejnar Danielsens Foundation No. 10-000405,
The Health Insurance Foundation No. 2012B058,
Sister Marie Dalgaard Foundation May 2012, and
Rigshospitalet, Copenhagen University Hospital.

WHAT IS KNOWN ABOUT THIS TOPIC?

• Family-centred care is acknowledged as fundamental for delivery of quality care in the neonatal intensive care unit.
• Person-centred communication is a key feature in Family-Centred Care associated with positive outcomes.
• To practice person-centred communication nurses need good communication skills.

WHAT THIS PAPER CONTRIBUTES

• The Guided Family-Centred Care intervention consisting of structured dialogues helps to forge a positive parent-nurse relationship that
supports parental stress management.
• The intervention for communication improvement in nurses sustains the sensitivity to person-specific issues by acknowledging the parent
perspective in NICU.

© 2013 British Association of Critical Care Nurses 9

 Communication in NICU
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APPENDIX A:
Reflection sheet: invitation to collaborate
Dear parents
Dialogue and collaboration:
Current issues that are difficult for you and your partner as a family with a
premature infant in NICU
We each play our own role
Only you know what you experience, feel, need, expect and wish for
Your knowledge and experience as well as that of your
partner and the staff is essential
When we collaborate it is essential that we are aware of one another’s
perceptions.
You, your partner and the staff might not agree on all issues.
You and your partner might have different experiences and needs
During our dialogues we will use several ‘reflection sheets’:
You can use these when you prepare for dialogues
We can use them together to explore what is most
important right now
Reflection sheets make things easier to talk about
Reflection sheets help you make important decisions
Reflection sheets help the staff understand your situation
Sincerely,
[Primary care nurse]
APPENDIX B:
Reflection sheet: collaboration dialogue
Current circumstances, issues or concerns applying to a family, admitted to the
neonatal unit
Date
Important issues discussed in the dialogue – according to the participants:
Perspective (parent):
Perspective (parent):
Perspective (nurse):
Decisions added to care plan:
© 2013 British Association of Critical Care Nurses
Communication in NICU
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APPENDIX C:
Reflection sheet: admission dialogue
The admission dialogue about an hour, depending on the issues we
need to discuss. At a later dialogue, we may resume issues that
were not covered in the first dialogue. This folder contains some
questions, which you can use to prepare for the dialogue. We base
this first dialogue on your answers to these questions.
We conclude the dialogue by on the following decisions:
What information is to be recorded.
How much you wish to participate for the time being.
How the staff can best support you at this time.
Schedule the next dialogue
Sincerely,
[Primary care nurse]
How do you feel right now (what in particular is troubling you)?
How did you experience your pregnancy, labor and delivery, and
admission to the neonatal unit?
Who supported you?
Is there anything concerning the care and treatment of your child you
need to know more about at present?
Is anything causing special problems, such as your family situation,
employment situation, childbirth, financial problems in connection
with admission, or housing problems?
How do you wish to participate in the care of your child at present?
APPENDIX D:
Reflection sheet: unfinished sentences
Follow-up dialogue regarding values, experiences and needs. You may use this
reflection-sheet, as preparation for our next dialogue. On this sheet you are to
complete the sentences, according how you feel right now. We base the
dialogue on what you and your partner each have written.
I experience NICU admission with my child as . . .
I wish I could . . .
I find it difficult to . . .
It was a good thing that . . .
11
 Communication in NICU

APPENDIX D: APPENDIX E:
Continued Reflection sheet: discharge dialogue

The worst thing about my child’s situation is . . . At discharge from NICU.

The happiest experience I had was when . . . This dialogue is based on the answers to the questions below.
The saddest experience was when . . . We conclude the dialogue by the following decisions:
I feel I can handle the situation when . . . What information should be recorded.
I cannot stand it, when . . . What you need during discharge.
I feel as a parent, when . . . How the staff can best assist you at this time.
I experience that the collaboration with the staff is . . . Sincerely
I am happy, when . . . [Primary care nurse]
I would like to know more about . . . How have you experienced your child’s admission to the neonatal unit?
Something that may give problems back home is . . . How have you experienced your child’s transfer or discharge?
I think that my family/friends . . . Is there something you are particularly looking forward to?
I get good support from . . . I would like to get more support from . . . Is there something worrying you?
What I wish most of all is . . . Is there anything you need to know more about?
Do you know who to contact if you experience problems or have any questions?

12 © 2013 British Association of Critical Care Nurses

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