1

BEST PRACTICES IN FAMILY CENTERED CARE IN THE NEONATAL INTENSIVE

CARE UNIT

KATYA ANN KIRKLAND

____________________

A Thesis Submitted to The Honors College

In Partial Fulfillment of the Bachelors degree

With Honors in 

Nursing

THE UNIVERSITY OF ARIZONA

DECEMBER2022
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Abstract

The purpose of this thesis is to determine best practice recommendations for family

centered care in the neonatal intensive care unit. The care received in the NICU has an impact on

the outcomes of the neonates as well as their parents who have to endure the stress and bare the

financial cost of having a baby in the NICU. A literature review was conducted to identify

evidenced based recommendations for FCC that would positively impact patient outcomes and

parental stress. These recommendations provide hospitals and nurses with guidelines for

implementing FCC in their own NICUs.

The best practice recommendations for family centered care in the NICU include high

parental involvement in the neonates’ care through education on bathing, changing diapers,

checking temperature, infant development, hand hygiene, feeding methods, skin to skin contact

and infection control. Additionally, adequate space and staffing need to be available for nurses to

provide education and families to spend sufficient time in the NICU. Finally, virtual visitation

must be available for families who cannot be present in the NICU. The final chapter proposes an

implementation and evaluation plan using the Plan-Do-Study-Act framework.

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CHAPTER 1

Statement of Purpose

The purpose of this thesis is to develop evidence-based practice recommendations for

nurses and other health care professionals on implementing family-centered care in the neonatal

intensive care unit.  This thesis will cover the importance and background of the issue followed

by a review of the current literature. Practice recommendations based on research evidence will

be created in addition to a proposed plan for implementation and evaluation.

Background of Issue Importance

Care in neonatal intensive care units (NICU) has been evolving over the years with the

incorporation of an ever-widening range of interventions that improve patient outcomes. Family-

centered care is one such approach that has enhanced the care provided in the NICU. While

family-centered care has been a standard of care in many other hospital units for decades, it has

just recently become the standard of care in many NICUs across the world. It was initiated in the

United States in 1992 to promote parental involvement and decision-making in and about the

care of their infant (Neu et al., 2020). Family-centered care (FCC) in the NICU involves

providing care for the neonate that includes the family more actively through education and

participation. Some key features of family-centered care include mothers and fathers spending

increased time visiting and holding their baby as well as learning and performing general care

such as feeding, changing, and bathing their baby. Further, FCC often aims to increase skin-to-

skin contact rates which have been shown to positively impact babies’ health. Lastly, rooming in

is an aspect of FCC that is becoming more prevalent in NICUs allowing parents unrestricted

visiting time with their baby.

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The importance of FCC is intensified by the large variety of causes that lead a newborn to

end up in the NICU. Infants can be admitted to the NICU for respiratory distress, hypoglycemia,

jaundice, neonatal abstinence syndrome, congenital diseases, and more, creating a substantial

population of NICU patients (Al-Wassia & Saber, 2017). Additionally, one in ten babies are born

preterm (born at less than 37 weeks gestational age) in the United States with the majority of

these infants being admitted to the NICU (CDC, 2021). Another prevalent risk factor for preterm

birth and extended lengths of newborn admission is a lack of access to prenatal care (Holcomb et

al., 2021). This problem is evidenced by 43% of black women, 35% of Latinx women, and 23%

of white women reporting barriers to prenatal care in a 2020 study (Fryer et al., 2020). The wide

variety of maternal and infant factors that cause admission to the NICU demonstrate the

importance of implementing family centered care during these babies’ and their parents’ stays in

the unit.

Significance of the Problem

Family centered care implementation and evaluation has been a challenge since it was

initiated due to a lack of a clear definition for FCC components and a lack of model fidelity

during implementation (Franck & O’Brien, 2019). This absence of clarity when it comes to

evaluating family centered care highlights the importance of recognizing its benefits and

developing a guideline that could be utilized in hospitals that are without a structured plan.

Further, family-centered care proves its significance because it can improve health outcomes in

infants and newborns that receive care in the NICU. One of these outcomes is the average length

of stay. The average length of stay not only shows the time it takes for these infants to become

healthy but also directly correlates to the cost of care. Neonatal intensive care costs 26.2 billion

dollars annually. While neonatal intensive care is thought to be cost-effective the average cost of
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the stay for a preterm infant staying for 2.2 days was 2500-2900 USD (Cheah, 2019).  This cost

falls on parents and can often lead to excessive medical bills that are debilitating to the family.

When the family cannot afford to pay, the hospital is forced to absorb the cost.

In addition to the financial cost, having a baby in the NICU takes an emotional toll on the

family. While their baby is in the NICU they must choose between going back to work, caring

for any other kids at home, and being with and supporting their baby in the NICU which can lead

to feelings of excessive stress or guilt. If parents can devote substantial time to being in the

NICU, it is still emotionally taxing to be concerned for their baby’s health or their ability to

survive. An additional improved health outcome is increased breastfeeding rates in babies that

can feed in the NICU. Breastfeeding has been shown to improve gastrointestinal function and

prevent illness in the infant. It also decreases the rate of hospitalization and outpatient visits in

the newborn’s first year of life (Meek, 2021).  These improved health outcomes contribute to a

strong case for implementing FCC in the NICU. 

Relevance to Nursing

Care for patients in the NICU has often fallen solely to the nurses staffed on the unit. While

nurses do an excellent job of providing high-quality care, traditional care is lacking in aspects

that family-centered care excels. With traditional care in the NICU families are often deficient in

experience when it comes to caring for their newborns. Further, they are not always taught or are

hesitant to care for their infant because of a fear of harming them. As stated previously, FCC

focuses on catering not only to the patient’s needs but the parent’s needs as well, which should

include how to care for their infant. 

Additional relevance to nursing is evidenced by the implementation of family-centered care

falling almost exclusively on the nurses. During an infant's stay in the NICU, the care that could
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be provided by the parents is often done by the nurses. For example, taking the infant's

temperature or changing its diaper. Therefore, when parents or caregivers are being taught the

proper ways to care for their newborn their teacher is going to be the nurse. Discharge teaching is

another aspect of nursing that is crucial to patient success. Through FCC nurses can provide

teaching to the parents on how to care for their child at home. During these interactions, the

nurses also develop relationships with the families of the infants they are caring for. Having

professional yet compassionate and caring relationships with the parents is an important part of

successfully implementing family centered care in the NICU.

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Chapter 2

Review of Literature

Chapter two is a review of scientific literature A literature search to evaluate this

intervention was guided by the following PICOTS question: How does family centered care (I)

compared to traditional care (C) of the neonate and their family (P) improve the health of the

infant (O) during the infant’s stay in the NICU (S/T)?  The PubMed database was used to search

for relevant literature published between 2017 and 2020. Search terms included “family centered

care in the NICU”, “benefits of FCC in the NICU”, “cost of FCC in the NICU”, “virtual

visitation in NICU”, and “perceptions of FCC in the NICU”.

Results of Literature Review

Outcomes Associated with Family Centered Care in the NICU

Verma et al. (2017) conducted a randomized control trial that assessed the impact of

family centered care on nosocomial infection rates. The sample consisted of 295 neonates and

their parents that were recruited to participate in the trial. The study took place in Northern India

in a tertiary nursery that also had a step downside for neonates that required less intensive care.

There were 147 babies in the control group and 148 babies in the intervention group. Each parent

in the intervention group went through a structured training program for a supervised delivery of

limited care to their baby. The data collected on nosocomial rates was determined to be any

episode of sepsis developing 72 hours or more after hospitalization. The researchers also wanted

to document the effects of the intervention on mortality, the median duration of stay, the

breastfeeding rate, and the culture-negative nosocomial infection rate.

The results of the study were that there was not a significant difference between the

nosocomial infection rates in the control and intervention groups. In the control group, there
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were 38 nosocomial infection episodes compared to 37 in the intervention group. The median

duration of hospitalization in the control group was eleven days and in the intervention group

was eleven and a half days. The mortality rate in the control group was 8.8% and in the

intervention group only 6.8%. The only statistically significant finding was that breastfeeding

rates improved in the intervention group. The breastfeeding rate in the control group was only

66.7% compared to 80.4% in the intervention group (Verma et al., 2017).  One strength of the

study was the limited exclusivity they used in choosing the parents to participate in the study.

Having a more inclusive population allowed the study to be more generalizable. One weakness

was the sample size because it was too small to detect more minor differences between groups.

Lv et al. (2019) assessed a family-centered care intervention on clinical outcomes of very

low-birth-weight infants using a quasi-experimental design. The study was conducted at the

Hunan Children’s Hospital in Changsha, China from June 2016 to June 2017. There were 319

neonates recruited with 163 in the control group and 156 in the intervention group. The parents

in the intervention group received education on bathing, changing diapers, checking temperature,

infant development, hand hygiene, feeding methods, skin-to-skin contact, and infection control.

The outcomes that the researchers were interested in monitoring were discharge weight,

breastfeeding rates, gastric feeding days, length of stay, and hospital expenses. This data was

taken from the infant’s hospital record.

The results of the study were that infants in the intervention group weighed more at

discharge than the control group. Breastfeeding rates and days of total parental nutrition also

improved in the intervention group. The number of days the infants spent with gastric feeding

was decreased in the intervention group. There was no difference in the length of stay and

hospital expenses between the two groups (Lv et al., 2019). One strength of the study was that
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their results were similar to or confirmed by previous studies. The study had a few limitations

including the use of a convenience sample and their inability to blind nurses to the intervention

because they had to participate in it (Lv et al., 2019).

The purpose of Lester et al. (2016) is to determine whether the single-family room (SFR)

NICU is associated with improved 18-month neurodevelopmental outcomes in infants. The

original study was a quasi-experimental cohort study that focused on both medical and cognitive

outcomes. Infants born at less than 30 weeks were included in the study with 123 being in an

SFR NICU and 93 in an open-bay NICU. The 18-month follow-up analyzed the cognitive

function of the infants as well as maternal involvement during the stay (Lester et al., 2016). The

results of the original study found that medically, SFR NICU babies weighed more at discharge,

had higher rates of weight gain, less sepsis, fewer medical procedures, less pain, and less

lethargy (Lester et al., 2014). The results of the follow up found that mothers who were in the

SFR were 1.5x more likely to have high maternal involvement compared to mothers in the open

bay NICU. The type of NICU did not affect cognitive development. However, infants who had

high levels of maternal involvement had significantly higher cognitive and language composition

scores in addition to greater receptive and expressive communication scores. All had a p value of

less than 0.002. Further, the number of days of maternal involvement was higher in the SFR than

in open bay NICU with a p-value less than 0.000. Lastly, the length of stay was shorter in the

high maternal involvement SFR than in the high maternal involvement open bay NICU with a p-

value of 0.024 (Lester et al., 2016).

Data for this study was collected and analyzed through the patients’ charts as well as the

Bayley-III Cognitive, Language, and Motor Composite scores, Receptive and Expressive

Communication scores, and Fine and Gross Motor subset scores (Lester et al., 2016). A strength
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of this study was the variety of aspects assessed during the study. This allowed the study to

highlight all the benefits of an SFR rather than isolated features such as length of stay. Another

strength of the study was its large sample size which could be applied to the rest of the

population. However, a limitation is that all infants were born at less than 30 weeks gestation

which excludes a relatively large population of the NICU. The last strength of the study is that it

took place over a long period of time. The original study suggested initial improvements in SFR

NICU babies compared to open bay but the 18-month follow-up allowed confirmation that the

effects were long-lasting and not only medical but neurodevelopmental as well.

Healthcare Providers' Perceptions of FCC in the NICU

Mirlashari et al. (2020) conducted a qualitative descriptive study about the perspective of

nurses and physicians on the challenges of implementing family centered care in the NICU. The

study took place at five different hospitals that are the main centers for neonatal intensive care in

Tehran. There were twenty-five nurses and fifteen physicians interviewed in focus groups of

seven to nine people. There were three focus groups done with nurses and two done with

physicians all of which lasted for thirty to fifty minutes. Prior to the focus groups, all participants

filled out a questionnaire that collected their socio-demographic information and work

experience in the NICU. During the focus group participants were asked open-ended questions

focused on family centered care implementation in the NICU.

The results of the study showed that there were three common challenges identified in

implementing family centered care in the NICU. The first was a power imbalance that was

broken into the subcategories of the medical authority of healthcare professionals and

unquestioned physician power. Participants stated that they felt that parents wanted the health

care providers to make all decisions and did not trust themselves in the care of their baby. Many
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of the nurses and physicians agreed that parents do not know the best way to care for their

neonates. The second challenge was psychosocial issues which were divided into fear, high

stress atmosphere, unresolved family difficulties, and discouragement of fathers’ involvement in

care. Participants explained that many parents felt fear about being able to take care of their baby

or being judged for having a preterm baby. The high stress setting referred to the difficulties of

working in a high acuity setting created by the increased need for care of patients and families

and conflicts between doctors and nurses. Unresolved family difficulties were a challenge as well

because some parents could not be at the hospital as often because of other children requiring

care or their work, both of which impacted the quality of care. Lastly, discouragement of the

father’s involvement, which nurses felt was at times necessary because some fathers would be

more focused on the nurses rather than their own child. The final issue was structural limitations

which were divided into policy restriction and organizational limitations. Participants discussed

the lack of leadership in family centered care as well as the failure to include family centered

care in the hospital’s policy and philosophy. These structural problems made providing care

more challenging since it was being done without clear guidelines to follow (Mirlashari et al.,

2020).

This study lacked the parents’ perspective which weakened its results because the only

issues addressed were ones brought forward by healthcare providers. This left out other possible

challenges felt by the parents. Additionally, it did not give the parents the opportunity to refute or

quantify the degree of severity of each issue the healthcare providers discussed. The study did

have in-depth interviews which strengthened the results by providing larger quantities of data

with more specific descriptions of the challenges.

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The purpose of Heidair & Hamooleh (2019) was to understand nurses’ perceptions of

FCC in NICUS. 18 NICU nurses with at least 4 years of experience participated in the study. The

study was a qualitative design that used the conventional content analysis method. The study

took place at two level III NICUs in two teaching hospitals in Iran. Data was collected through

semi-structured interviews lasting 35-45 minutes over a six-month period. The first question

asked was “what is your opinion about FCC in the NICU” which was followed by questions

asking for elaboration on their answers (Heidair & Hamooleh, 2019).

The results of the study found that there were two categories identified including

prerequisites for providing FCC and parents’ participation. The first category was broken down

into first having suitable facilities, such as sufficient physical space for both the mother and

father and second having adequate personnel to provide FCC. The second category was also

broken down into two subcategories. The first was parents’ attachment to their neonate, meaning

that they felt FCC was easier to implement when the parents wanted to participate. The second

subcategory was parents’ training. Nurses felt that FCC went better when the parents received

training from the nurses, however, not all nurses felt adequately prepared to provide training

(Heidair & Hamooleh, 2019).

A strength of this study was that in-depth interviews were conducted to obtain a deeper

understanding of nurses’ opinions on FCC since they are often the ones providing it. Another

strength was that nurses were interviewed from two hospitals allowing for more generalizability

to other NICU nurses. A weakness of this study was that it only interviewed 18 nurses which is a

small sample size making it less applicable to the entire NICU nurse population.

Family Perception and Experiences with FCC in the NICU

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Neu et al. (2020) conducted a qualitative descriptive study to compare maternal

experiences at NICUs using FCC as their standard of care in 2020 with maternal experiences at

NICUs using non-FCC twenty to thirty years ago. Fourteen mothers were recruited to participate

in the study and were interviewed about their experiences from birth through their infants’ stay

in the NICU. The mothers were recruited from two teaching hospitals in the western United

States. The first was a children’s hospital and the second was a university-based birthing

hospital. The interviews consisted of open-ended questions about the mothers’ pregnancy and

birthing experience, as well as questions on visiting and social support, holding and feeding the

baby, and lastly concerns about discharge. During the interviews, the researchers asked probing

questions to clarify the responses from the mothers. The criteria for the mothers were that their

baby was 32-33 weeks postconceptional age and had to stay in the NICU for at least 2 weeks. A

literature review was conducted to compare these experiences with mothers from twenty years

ago. This literature review used thirty-seven studies from 1993 to 2003 and was organized into

four components of family centered care including visiting, general caregiving, holding, and

feeding.

During the interviews, there were five common themes that the mothers who experienced

FCC discussed. The first theme was visiting which showed that most mothers spent at least 6

days of the week visiting with their baby. The second was general caregiving in which mothers

stated they were bathing and changing their baby within the first week of their stay. The third

theme was holding the infant which mothers reported doing by day three of their infant's stay and

were able to hold them for one to seven hours per day. The fourth was feeding which showed

that mothers found it very easy to obtain assistance with breastfeeding. Finally, the fifth category

was maternal ideas for improvement which consisted of having special places for NICU families,
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wireless monitors, multiple chairs, and the nurse reaching out to the parents more frequently

when they are not able to be at the hospital. When compared to the results of the literature review

it was found that the mothers who received family centered care had improved times in which

they were able to start providing general care of their infant and had more access to breastfeeding

resources (Neu et al., 2020).

One strength of this study was the in-depth interviews that were conducted. The

interviews provided a large quantity of data that allowed researchers to create specific categories

for the interview information to be placed. The study was weak in applicability because of the

limited number of participants. Additionally, this study only used a literature review to compare

prior mothers’ experiences so the quality of the data is lower than it would have been had they

interviewed mothers from twenty years ago.

The purpose of Balbino et al. (2016) is to evaluate the effects of Patient and Family-

Centered Care Model on parents and healthcare perceptions and parental stress. The study was a

quasi-experimental study that was conducted in a NICU at a university hospital in Brazil. 132

parents of hospitalized newborns participated in the study as well as 57 healthcare professionals.

The parents were split into two groups of 66 with half being in the pre-intervention phase and the

other half in the postintervention phase. The intervention was the implementation program of the

patient and family centered care model in the NICU. This consisted of an agreement on the

proposed changes to the NICU, transitioning to the new best practice guidelines, and evaluating

the program. There was a statistically significant improvement in parental perception of respect,

collaboration, and support with a p-value of less than 0.05. There was also an improvement in

staff relation to the families with a p-value of 0.041. Lastly, there was a significant reduction in

parental stress with a p-value of 0.048 (Balbino, et al., 2016)

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Data was collected using a variety of surveys. To analyze staff and parental perceptions

of family centered care Perceptions of Family Centered – Parents and Perceptions of Family

Centered – Staff were used. Each consisted of 20 questions divided into three domains including

respect, collaboration, and support. Parental stress was measured using the Parent Stress Scale:

NICU. It contained 26 questions divided into three categories including “baby looks and

behaves”, “sounds and sights”, and “alteration in parental role” (Balbino, et al., 2016). A strength

of this study was that it was a quasi-experimental study. Although it lacks randomization it is a

higher level of evidence than qualitative studies which are often done to analyze the perceptions

and feelings talked about in this study. Secondly, it had a sample size of over 100 parents which

makes it generalizable for that population. A limitation of this study is that it only measured two

outcomes being perceptions of FCC and parental stress. To further determine FCCs effectiveness

a more in-depth study would need to be conducted.

Guttmann et al. (2020) conducted a qualitative descriptive study on parental stress in

relation to the use of bedside telehealth in a NICU. It was conducted at the Children’s Hospital of

Philadelphia. Forty-eight parents participated in the study with twenty-one parents using the

AngelEye camera and twenty-seven not. AngelEye was a camera installed at the bedside

allowing parents to see the neonate at any time during the day or night. Parents who participated

in the study were asked to fill out the Parent Stress Scale – NICU version. Data was collected on

parental stress in the following four domains: sights and sounds in the unit, the appearance of the

baby, the relationship with the infant and parental role, and staff behaviors and communication

(Guttmann et al., 2020).

To analyze the data the Wlicoxon rank sum test was used and statistical analysis was

conducted through STATA SE. The study found that parents who used the camera had
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significantly less stress compared to those who did not use the camera in three of the four

domains. They had less stress related to the sights and the sounds of the unit with a p-value of

0.0265, the appearance of the baby with a p-value of 0.0246, and the relationship with infant and

parental role with a p-value of 0.0184. Nine percent of parents who used the camera found staff

behavior and communication stressful compared to twenty nine percent of parents who did not

use the camera, but the results were not statistically significant with a p-value of 0.0534

(Guttmann et al., 2020).

A strength of this study was having a large sample size of over forty participants. Due to

having a large unit they were able to secure many participants in a short period of time

preventing the passage of time from confounding the results. Some weaknesses of the study were

that they did not collect patient demographics which could have impacted the results. Further, the

study was limited to a convenience sample which can allow for bias (Guttmann et al., 2020).

Developing Family-Centered Care in a Neonatal Intensive Care Unit: An Action Research

Study

The purpose of this study was to develop, implement, and evaluate family-centered

interventions to promote parental involvement in caregiving in the neonatal intensive care unit.

The study took place in a regional NICU located in England. This study used a participatory

action research approach that involved nurses, multidisciplinary team members, and parents in

the intervention, implementation, and evaluation portions of the study. The interventions in care

included improving skin-to-skin contact and maximizing parental presence by allowing them to

attend rounds, clinical procedures, and change of shift report. A total of 67 healthcare

professionals including RNs, charge nurses, nurse practitioners, and support workers participated

in the study. There were also seventeen parents whose babies had a minimum stay of ten days
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and were over 27 weeks gestation that were a part of the study (Skene et al., 2018). The study

was conducted in three phases. The first phases involved defining parental involvement through

FCC, identifying factors that affect the parent-infant relationship, and establishing evidence-

based interventions to be implemented. Phase two tested interventions through three action

phases that were each refined through the process of planning, acting, observing, reflecting, and

replanning. Finally, in phase three the success of the interventions was evaluated and analyzed

(Skene et al., 2018).

The results of the study showed that the interventions were successfully implemented on

the unit and nurses had positive reports about the improvements to family centered care. There

was a statistically significant improvement from phase one to phase three in staff perceptions of

FCC, information sharing between parents and staff, family support, parental involvement, and

competency in FCC. Additionally, nurses reported a shift in willingness to involve parents more

in care, a more relaxed and less rule driven culture, and a reduction in nurse workload (Skene et

al., 2018).

From the parental perspective diaries with data on skin-to-skin, parental involvement,

confidence to care for your baby, the relationship with their nurse, and satisfaction with the level

of involvement were analyzed. With skin-to-skin-to-contact recorded entries went from 35% in

phase one to 53% in phase three showing a significant improvement. Parental involvement in

tasks such as mouth care and position changes increased from 56% in phase one to 70% in phase

three Parents reported gaining confidence during phase three as opposed to feeling inadequate in

phase one. The relationship between patient and nurse was reported to be more therapeutic in

phase three as opposed to phase one where parents felt like they did not know what was expected
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of them in the NICU. Lastly, satisfaction with parental involvement when up from 41% in phase

one to 60% in phase two (Skene et al., 2018).

The data was collected through questionaries, focus groups, interviews, and patient

diaries. The qualitative data were analyzed using Framework and the quantitative data were

analyzed using descriptive and t-test statistics (Skene et al., 2018). A strength this study

possessed was the in-depth interviews of nurses and parents. This allowed the study to gain

perspectives from each ensuring the interventions were successful for both the staff and families.

In contrast, there were some limitations to the study. First, the lead researcher was also a lead

nurse on the unit making it possible that her presence influenced the outcomes and success of the

intervention. This could affect its applicability to other NICUs. Further, the study chose parents

that were willing and able to spend lots of time with their infant (Skene et al., 2018). Many

parents are restricted in the amount of time they can visit which again reduces the study’s

applicability to all NICU families.

Conclusion

In summary, family centered care has been shown to have wide ranging benefits. These

include mothers spending more time visiting their babies, as well as participating in more of their

care, such as diaper changes and bathing, sooner into their baby’s’ stay. Further, breastfeeding

rates are shown to be increased when FCC is being done. Focusing on the parents, FCC was also

shown to reduce parental stress and improve their relationship with the staff. When looking at

single family rooms, an important aspect of FCC, parental involvement in care is higher and the

babies were healthier in terms of decreased infection and procedures and increased weight at

discharge. It is also found that the cognitive function of babies is improved when there is high

parental involvement in the care of the infant.

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Throughout the literature, the most significant challenge with FCC is its implementation.

Nurses identified the need for adequate facilities and staffing. They also mentioned the

challenges of parental fear in caring for their baby, any unresolved family conflict between the

parents, and the greater need for paternal participation as well. The largest gaps in knowledge

around FCC lie in its implementation. FCC seems to have a different definition in every hospital

with different aspects being implemented in each. NICUs interested in implementing FCC would

benefit from an implementation plan fit for their facilities and resources.
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CHAPTER 3

Best Practice Recommendations: Family Centered Care in the NICU

The purpose of this thesis was to create best practice recommendations for healthcare

professionals working in neonatal intensive care units where family centered care is being

implemented or practiced. These recommendations are presented in Table 1 with the

corresponding level of evidence for each article. Family centered care lacks clear guidelines, so

the recommendations are intended to be used as a guide for NICUs to create their own

guidelines.

Table 1

Best Practice Recommendations for Family Centered Care in the NICU

Level
Recommen of
Rationale References
dation Evide
nce
Increased
discharge
Education Lv, B., Gao, X.-R., Sun, J., Li, T.-T., Liu, Z.-Y., Zhu,
weights,
should be L.-H., & Latour, J. M. (2019, April 12). Family-
and
provided to centered care improves clinical outcomes of
breastfeed
parents very-low-birth-weight infants: A quasi-
ing rates. Level
on bathing, experimental study. Frontiers in pediatrics.
Decreased III
changing Retrieved September 29, 2022, from
TPN days
diapers, https://pubmed.ncbi.nlm.nih.gov/31032240/
and gastric
checking
feeding
temperature,
days.
infant
developmen Heidair, H., & Hamooleh, M., (2019, August 30).
Nurses felt
t, hand Nurses’ Perception of Family-Centered Care in
FCC was
hygiene, Neonatal Intensive Care Units. Journal of
easier to
feeding Pediatric Intensive Care. Retrieved May 1,
implement
methods, 2022, from
with Level
skin-to-skin https://www.ncbi.nlm.nih.gov/pmc/articles/PMC
adequate IV
contact and 6978175/
parental
infection
training.
control
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Caregiver
Mothers
should Neu, Madalynn, Klawetter, Susanne, Greenfield,
reported
participate Jennifer, et al. (2020). Mothers' Experiences in
feeding Level
in feeding, the NICU Before Family-Centered Care and in
and VI 
changing, NICUs Where It Is the Standard of Care.
changing
and bathing Advances in Neonatal Care, 20, 68-79.      
babies by
their baby 
day 3 of
their stay.
SFR
NICU
babies
weighed
more at
discharge,
had
Lester, B., Salisbury, A., Hawes, K., Dansereau, L.,
higher
Bigsby, R., Laptook, A., Taub, M., Lagasse, L.,
rates of
Vohur, B., Padbury, J. (2016, October). Single-
weight
Family Room Care and Neurobehavioral and
Families gain, less
Medical Outcomes in Preterm Infants. American
should stay sepsis,
Academy of Pediatrics. Retrieved May 10, 2022,
in single less
from
family medical
https://publications.aap.org/pediatrics/article-
rooms in the procedure
abstract/134/4/754/32962/Single-Family-Room- Level
NICU s, less
Care-and-Neurobehavioral-and? II 
pain and
redirectedFrom=fulltext
less
lethargy.
Increased
maternal
involveme
nt and
decreased
length of
stay.
There Higher Lester, B., Salisbury, A., Hawes, K., Dansereau, L.,
should be cognitive Bigsby, R., Laptook, A., Taub, M., Lagasse, L.,
high and Vohur, B., Padbury, J. (2016, October). Single-
maternal language Family Room Care and Neurobehavioral and
involvement compositio Medical Outcomes in Preterm Infants. American
in NICU n scores Academy of Pediatrics. Retrieved May 10, 2022, Level
care.   and from II 
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 22

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Summary of Best Practice Recommendations

 23

Implementation of FCC in the NICU is a relatively new practice without standardized

guidelines. To ensure it is done effectively the recommendations in table 1 provide a framework

for providing FCC. The first recommendation that sets up for FCC is to ensure adequate staffing

and adequate facilities. Nurses have reported FCC is easier to implement when there is adequate

space for the parents to be at the bedside of their infant without crowding the unit. Further, there

needs to be adequate staffing for the training of the parents in the care of their infant. Without

additional staffing, it can be a burden on the nurse to provide care as well as education to the

family (Heidair & Hamooleh, 2019). Secondly, FCC needs to be defined as well as the factors

affecting the parent-infant relationship. A clear definition allows nurses to provide clear and

complete instruction to the parents which in turn increases maternal involvement and improves

both the parents' and nurses' experience with FCC (Skene et al., 2018).

High maternal involvement should also be a standard of FCC due to its improved

cognitive outcomes in NICU babies (Lester et al., 2016). To ensure maternal involvement is

feasible and increase the chances of it families should stay with their infant in single family

rooms when available. Having single family rooms not only increases maternal involvement but

also improves a variety of health outcomes in the neonate such as discharge weights and

decreased infections (Lester et al., 2016). When being physically present in the NICU is

unattainable for parents or the facility is not equipped for it, there should be virtual visitation set

up for parents. A bedside camera allows parents to be able to see their baby decreasing their

stress about spending time away from their infant (Guttmann et al., 2020).

An important part of FCC is the education the family receives about caring for their

infant. The recommendation includes education on bathing, changing diapers, checking

temperature, infant development, hand hygiene, feeding methods, skin-to-skin contact, and
 24

infection control. These subjects not only allow the parents to participate in the care but also

learn how to do it safely. When parents are taught and provide this care the infant will have

better outcomes such as decreased parental and enteral nutrition needs and improved

breastfeeding rates (Lv et al., 2019). Further, when parents receive sufficient training and

education it is easier for the nurses to implement and support families in FCC (Heidair &

Hamooleh, 2019). Lastly, assuming adequate education was provided mothers should be

changing, feeding, and bathing their infant as soon into the stay as possible. The use of standard

FCC education allows this care to be performed sooner than with standard NICU care (Neu et al.,

2020).

These recommendations could impact many NICUs by providing guidelines for what the

facility needs to provide or obtain to ensure FCC can be implemented. They also provide a

framework for what education the parents or caregivers should be provided and subsequently

what care they can participate in. These recommendations also allow for the ease of

implementation by nurses by creating a clearer more structured process of implementation.

Chapter four will present a dissemination plan for these recommendations.

CHAPTER 4
 25

The first three chapters of this thesis discussed the significance of family centered care, a

review of the current literature on FCC, and best practice recommendations for FCC in the

NICU. This chapter of the thesis will discuss how to implement the best practice

recommendations for adopting the FCC model of care in a NICU. Plan-Do-Study-Act is the

framework that will be used to create this implementation plan.

Plan-Do-Study-Act is used to test a change that has been implemented. It allows an

intervention to be implemented, evaluated, and changed as necessary to then be tested again. It

consists of four stages starting with plan. Plan consists of identifying a change in practice that

will be implemented, what is going to be tested and how including identifying the goal and

stakeholders that will be involved. Do consists of the actual implementation of the change and

observing the effects of the intervention. Study is the evaluation of the intervention and seeing

whether the goal was met. Finally, Act is determining the effectiveness of the change and what

could be done to improve the change in the next cycle (PDSA, n.d.).

The first part of the plan will be contacting the nurse manager, house supervisor, and

Director of Neonatology of a selected NICU to obtain permission to implement the change. The

plan and execution of the plan will need to be presented and approved. This will include

obtaining chairs at the bedside for parents to sit in and to facilitate skin-to-skin and feeding,

cameras installed on all cribs for parents who can’t be there in person, hand hygiene stations near

each crib, and identification of staff who will provide the education. If the facility has the space

for single family rooms those will need to be set up as well. All staff and the Developmental

Specialist need to be identified and informed of the change. A timeline will also be identified for

the intervention.
 26

The Do part of the implementation will consist of various parts. First, all the staff on the

unit including nurses, providers, speech therapists, patient care technicians, and respiratory and

occupational therapists will have to take two online learning modules. The first will consist of a

brief presentation of the research and benefits of using family centered care. The second module

will explain how family centered care will be implemented in the NICU. For all staff, it would

share that the family is allowed to be there for all care. Further, any care parents are able to

participate in should be taught and encouraged by staff. It will also include information on how

to use the bedside cameras and the benefits they provide for parents. For nurses, it will provide

education they should provide parents on bathing, changing diapers, checking temperature, infant

development, hand hygiene, feeding methods, skin-to-skin contact, and infection control

including a video demonstration of each. Staff will be given one month to complete the modules.

Cameras will be set up on all beds and instructions for how to access the camera will be

printed out for parents. Parents will also receive a pamphlet on family centered care and its

benefits in addition to what education they should be expecting to receive from their nurse. They

will also be provided with required videos to watch on the patient care they will be providing.

Surveys will also be printed and given to parents to fill out at the beginning and end of their stay.

Once the unit is prepared for implementation the study will take place over three months for

adequate data collection.

For the study section of the model, the effectiveness and outcomes of the FCC

implementation will be evaluated. This will be measured through the surveys parents fill out over

the course of their baby's stay and audits of the electronic health records. The survey will

measure the parental stress levels and how supported they felt by the staff. The electronic health

record will also be audited to determine breastfeeding rates, skin-to-skin contact, patient care
 27

done by parents including feeding, changing, bathing, and temperature checks, and length of

stay. Additionally, all staff will be given a survey to determine how they viewed the

effectiveness of the change and what challenges or barriers they faced to providing FCC.

The last section of the PDSA cycle is Act. The implementation will be considered

effective, and another cycle will not be needed if all outcomes are met. This would mean that

parents' stress levels were reduced, and they felt adequate support from staff. Further, parental

involvement in patient care activities is increased as well as breastfeeding rates and skin-to-skin

contact. They would also practice effective hand hygiene for infection control. There would also

be no issues with the bedside cameras. Lastly, staff experiences will need to be positive and lack

identification of any issues that need to be addressed.

In the case that any of these outcomes are not met successfully the plan will need to be

adjusted accordingly and the cycle will run again. Once the interventions are determined to be

effective the final implementation plan can be adopted by the unit for continuous use. Further, it

can be shared with other hospitals for widespread use.

Strengths, Limitations, and Recommendations for Future Research

A strength of this thesis is the review of the current literature. It ranges from level II to

level IV articles and covers a wide variety of aspects of FCC from patient outcomes to parental

and staff perceptions of FCC allowing for a comprehensive review of FCC. One limitation of this

thesis and the articles reviewed were the differing or lack of a clear definition of family centered

care. This lack of uniformity can decrease the generalizability of their combined results.

More research needs to be done on implementing family centered on neonatal units.

There was limited information on guidelines for implementation as well as defined aspects of

family centered care. Research on effective guidelines and subsequent implementation would
 28

allow hospitals to more easily begin introducing and adopting family centered care as their

standard of practice.

Summary

This thesis developed best practice recommendations for using family-centered care in

neonatal intensive care units by reviewing the literature on the topic. Background on the

importance of the issue and its relevance to nursing was also examined and discussed. Finally, an

implementation and evaluation plan was created to put these recommendations into practice in a

NICU. Nurses are at the forefront of family centered care and their implementation of it in their

own practice to positively impact the outcomes of their patients. Providing nurses and hospital

administrators education on this topic could lead to changes in the way their NICUs operate and

the importance they give to involving families in the care of their babies fighting to grow and

thrive in our NICUs.

 29

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