RESEARCH

Emotional Work of Neonatal Nurses in a

Single-Family Room NICU
Megan Doede and Alison M. Trinkoff

Correspondence
Megan Doede, PhD, RN,
Department of Family and
Community Health,
University of Maryland
School of Nursing, 655
West Lombard Street, Room
632, Baltimore, MD 21201.
mdoede@umaryland.edu
Keywords
emotional work
neonatal
NICU
nurse
private rooms
single-family room
ABSTRACT
Objective: To describe the emotional work of neonatal nurses in a single-family room NICU.
Design: Qualitative interpretive description.
Setting: A single-family room NICU in the mid-Atlantic region of the United States.
Participants: Fifteen nurses who worked in the single-family room NICU.
Methods: Data were collected from 110 hours of direct observation and 11 interviews over a 6-month period. We
focused on emotional demands using triangulation between interviews and observations to identify themes.
Conceptualization of emotional work informed interpretation.
Results: Four themes emerged: Parents Living on the Unit, Isolation of Infants in Rooms, Nurses’ Ability to Form Bonds and
Establish Trust With Parents, and Sheltering Nurses and Parents From Stressful Events on the Unit. Parents living on the
unit and the isolation of infants in private rooms increased the emotional work of nurses. Forming trust and bonds with
parents and sheltering parents and themselves from stressful events on the unit decreased nurses’ emotional work.
Conclusion: Care should be taken in NICU design because unit layout can affect the emotional work of nurses.
Understanding how neonatal nursing practice is affected by unit layout can help nurses and those who design NICUs to
create and promote optimal practice environments.
JOGNN, 49, 283–292; 2020. https://doi.org/10.1016/j.jogn.2020.03.001
Accepted March 2020

Megan Doede, PhD, RN, is
an assistant professor in the
Department of Family and
Community Health,
University of Maryland
School of Nursing,
Baltimore, MD.
Alison M. Trinkoff, ScD,
MPH, RN, FAAN, is a
professor in the Department
of Family and Community
Health, University of
Maryland School of
Nursing, Baltimore, MD.
The authors report no con-
flicts of interest or relevant
financial relationships.
N eonatal nurses care for medically unstable
infants and parents who are under duress.
This situation has been associated with increased
risk for occupational stress and burnout. NICU
nurses report greater fatigue, anxiety, and symp-
toms of depression than nurses on general wards
(Fujimaru et al., 2011), and recent studies indicate
that burnout in neonatal nurses remains a signifi-
cant problem (Profit et al., 2014; Twafik et al., 2017).
These are important concerns because they occur
along with other challenging working conditions,
including heavy workloads, time pressures, and
staffing inadequacies that are associated with lower
care quality and hospital acquired infections for
patients (Lake et al., 2016; Rochefort & Clarke,
2010; Rogowski et al., 2013, 2015).
NICU Layout and Effect on
Nursing Practice
Over the past 20 years, NICUs have transitioned from
the typical open-bay layouts to private, single-family
room configurations. Open-bay NICUs house multi-
ple infants, their parents, and nurses in one large
area, which allows nurses to easily assist and
communicate with one another and share tasks and
workloads (Shahheidari & Homer, 2012). In contrast,
single-family room layouts were introduced to give
parents greater privacy and protect infants from in-
fections (White, Smith, & Shepley, 2013). Despite
these benefits, single-family rooms have less visibility,
and nurses must rely more heavily on technology to
monitor infants and contact each other (Dunn,
MacMillan-York, & Robson, 2016; Shahheidari &
Homer, 2012). Because single-family room layouts
present communication and surveillance challenges
compared with open-bay layouts, some researchers
suggested that the single-family room layout is more
demanding and stressful for nurses (Domanico,
Davis, Coleman, & Davis, 2010; Dunn et al., 2016;
Hogan, Jones, & Saul, 2015; Stevens et al., 2012).
Bosch, Bledsoe, and Jenzarli (2012) studied 40
nurses who worked in the same NICU before and
after single-family room construction and found

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Published by Elsevier Inc. All rights reserved.
RESEARCH
The complex relationship between nurses’ emotional
health and the physical environments in which they
practice is not well understood.
decreased stress in nurses after they transitioned
to the new layout. However, they did not discuss
how unit layout might influence this finding.
Furthermore, Feeley et al. (2019) compared
54 nurses’ job stress and satisfaction before and
after occupancy of a new single-family room unit
and found no significant differences on either
measure.
In summary, there appears to be a complex
relationship between emotional health and the
physical environment in which neonatal nurses
care for infants. Because a description of these
complexities is currently absent from the litera-
ture, qualitative inquiry based on the concept of
emotional work with consideration of its ante-
cedents and consequences could be useful in
further describing these relationships. The pur-
pose of our analysis was to describe the
emotional work of neonatal nurses in a single-
family room NICU. It represents one objective of
a larger qualitative study on the emotional,
mental, and physical work of neonatal nurses in
single-family rooms.
Methods
Design
We used interpretive description, a method that
generates questions from the evidence and leads
the researcher into the field to collect data in a
way that is logical, systematic, defensible, and
relevant to clinicians (Thorne, 2008). The first
author (M.D.) performed 110 hours of field ob-
servations (56.5 hours of grand tour observation
of the unit and 54 hours of direct nurse observa-
tions) and 11 one-hour interviews with nurse
participants. We used constant comparative an-
alyses (Glaser & Strauss, 1966) to guide data
collection and triangulation between interviews
and observations to establish themes. The hos-
pital and University of Maryland, Baltimore Insti-
tutional Review Boards approved this study as
exempt human subjects research. Therefore,
written informed consent was not required.
Conceptual Framework: Emotional Work
Emotional work was first described by
Hochschild (1983) as the suppression of feelings
to sustain the proper professional demeanor ex-
pected in the workplace. For instance, nurses are
284 JOGNN, 49, 283–292; 2020. https://doi.org/10.1016/j.jogn.2020.03.001
Nurses’ Emotional Work in a Single-Family Room NICU
expected to display competence, extend
emotional support, and appear calm during
difficult situations, although they may inwardly
feel quite different. In a concept analysis of
emotional work in caring professions, Huynh,
Alderson, and Thompson (2008) proposed that
the antecedents of emotional work consist of the
interaction between organizational rules and
norms; the nurse’s individual attributes; and job
characteristics, including emotional demands
and frequency of interaction with others. The
consequences of high levels of emotional work
can be burnout, stress, and job dissatisfaction
(see Figure 1).
Cricco-Lizza (2014) studied emotional work in
NICU nurses and described the NICU as “a
cauldron of emotion confined in a small space”
(p. 619). She indicated that emotional work could
only be understood in the context of nurses’
emotional demands, which included working with
unstable infants and their highly anxious parents.
Organizational demands, such as adapting to
new technology, and the nurses’ own individual
attributes and coping strategies combined to
create a high level of emotional work that was
related to the tendency toward job stress,
burnout, and job dissatisfaction.
Setting
The setting was a 24-room Level IIIB single-family
room NICU in the mid-Atlantic region of the
United States. Level IIIB NICUs have the capa-
bility to provide comprehensive care to
extremely-low-birth-weight infants, defined as
those who weigh less than 1,000 g and are born
before 28 weeks gestation (American Academy
of Pediatrics, 2004). The neighborhoods that
surround the hospital are mixed in demographics
and income level. Approximately two thirds of the
infants and mothers who receive care in this NICU
are Medicaid recipients. The unit was first con-
structed as open bay, and the transition to single-
family rooms occurred about five years before
data collection. The NICU staff cares for nearly
500 infants annually who are born prematurely,
with congenital anomalies, and/or who need
special monitoring.
Unit layout and family spaces. The L-shaped
unit has two central nurses’ stations: one with
direct sight lines into four rooms and the other
with a direct sight line into one room; the
remaining 19 rooms have no direct sight lines
from either nurses’ station. Staff members use
family-centered care as a philosophical approach
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Doede, M., and Trinkoff, A. M. RESEARCH

Organiza onal Rules Nurse Job Demands

Social norms and support Interpersonal skills Emo onal demands
Social cues Work experience Degree of autonomy
Professionalism Frequency of interac ons
Work complexity

LEVEL OF EMOTIONAL WORK

Nurse job stress, burnout, and job dissa sfac on

Figure 1. Our conceptual framework for emotional work based on the concepts of Huynh, Alderson, and Thompson (2008).

(Williams, 2016); parents are encouraged to stay
24 hours a day in the private rooms to facilitate
bonding. Most rooms have a couch where one
person can sleep, a reclining chair, a television,
and a refrigerator for storing only breast milk. The
couch is in the back of the room separated by a
curtain. Rooms have sliding glass doors with
adjustable blinds that cover the room from view in
the hallway.
Staffing. Nurses care for one to three infants,
depending on the acuity of the infants’ conditions.
There is one charge nurse who does not have a
patient assignment. Charge nurses ideally cluster
nurses’ assignments to one area of the unit, but
continuity of assignments is the first priority.
Participants
Nurses from this NICU were recruited for direct
observation and interviews via e-mail, flyers, and
face-to-face conversations. Any nurses who pro-
vided clinical care, including charge nurses, were
invited; managerial nurses and advanced prac-
tice nurses were excluded. The primary author
(M.D.) initially used convenience sampling
recruitment and then continued with the use of
quota sampling until the final sample size was
determined to be reflective of various ages,
experience levels, and shifts among these
nurses. M.D. gave the participants a copy of the
research information form before interview and/or
observation. Potential risks or discomforts, ben-
efits, and the right to withdraw at any time were
discussed, and participants were given a chance
to ask questions. Overall, there were 15 nurse
participants, 11 of whom were interviewed and
eight of whom were directly observed; four
nurses participated in both activities.
Procedure
The primary author (M.D.), who is not an
employee of the unit or hospital, collected all data
between May and November 2017. The initial
data collection consisted of the grand tour ob-
servations in which the NICU as a whole was the
focus of analysis. The purpose of the grand tour
was to identify the major spaces, people, and
activities on the unit, with attention to what emo-
tions nurses displayed and where on the unit
these emotions were expressed (Spradley, 1980).
M.D. conducted observations from several van-
tage points throughout the unit but did not enter
patient rooms unless invited by a nurse and only
after a parent’s verbal consent to do so was
received. The grand tour comprised 56.5 hours of
observation over a 6-month period and continued
until redundancies in nursing activities were
noted. Each observation lasted from 1 to
6.5 hours and was completed during day, eve-
ning, and weekend shifts.
Overlapping with the grand tour, M.D. conducted
11 semistructured interviews to gain in-depth
understanding of nurses’ work and to triangulate
observations. Interviews took place at a conve-
nient time and location for each participant. The
opening prompt was “Tell me what it is like to work
in a single-family room NICU” if the participant
had prior open-bay experience or “Tell me what it
is like to work in the NICU” if the participant had

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no such experience. When participants brought
up the emotional or stressful aspects of their job,
they were prompted to elaborate.
The interview guide provided a framework but
remained flexible over the course of the interview.
Saturation in participant responses occurred at
about the seventh interview, which meant at that
point only limited novel information was obtained.
Despite this, four additional interviews were con-
ducted to ensure that no new data emerged and
that participants varied in age. Interviews lasted
45 to 60 minutes and were recorded with a digital
audio recorder. A transcription service was used
to transcribe interviews into Microsoft Word, and
transcripts were deidentified by the first author.
After the grand tour and interviews were
concluded, M.D. performed 54 hours of direct
observations over a 10-week period to view
nurses interacting with patients, parents, and
each other from the vantage point of patient
rooms. Direct observations lasted between 4 and
6 hours and were completed during day (7 a.m.
to 7p.m.), night (7 p.m. to 11 p.m.), and weekend
shifts. Parents who agreed to participate were
observed interacting with the nurse. M.D. took
handwritten notes and was careful to not distract
the participants from patient care. Direct obser-
vations were complete when similarities in nurses’
activities, behaviors, and conversations were
noticed and after salient interview data were
verified through observations.
M.D. collected field notes using the method
described by Schatzman and Strauss (1973),
which consists of three categories: observational,
a direct account of observed behavior; theoret-
ical, an account of ongoing analysis and inter-
pretation; and methodological, an account of
lines of inquiry to pursue. No personal identifiers
were used while recording field notes; partici-
pants were simply referred to as “RN.” Notes
were typed into Microsoft Word within one week
of collection, and additional details were added at
that time. We used NVivo (Version 10; QSR
International, 2012) to organize and manage the
cleaned, deidentified observational notes and
interviews.
Data Analysis
Analysis began during the grand tour observation
and continued as observational field notes and
interviews were transcribed. For this study, we
(M.D. and D.W.) identified portions of the tran-
scripts in which participants spoke about
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Nurses’ Emotional Work in a Single-Family Room NICU
emotional demands or stress during work and
analyzed the comments. We began by coding
broadly and then merged the codes into themes
to explain patterns of emotional demands on
nurses in the single-family room layout. Huynh
et al.’s (2008) conceptual framework of care-
giver’s emotional work guided interpretation (see
Figure 1).
The first author (M.D.) generated an audit trail that
consisted of theoretical and methodological
notes, analytical notes, and the coding scheme.
We used triangulation between observational and
interview data sources by comparing information
obtained from each source to support credibility
(Hunt, 2009). For example, we felt confident that
participants’ accounts of stressful experiences
during interviews were credible if they also were
observed in similar stressful situations on the unit.
We used a thick description in which we selected
pithy exemplars to support reasoning and
establish analytical logic (Glaser & Strauss, 1966;
Thorne, 2008). M.D. performed member checks
during interviews and direct observations. These
provided participants with a data-close interpre-
tation that supported descriptive validity
(Maxwell, 1992). The second author (A.M.T.), an
expert in nurse occupational health, and D.W., an
expert in qualitative methods, served as sources
of expert validation (Sandelowski, 1998) along
with a nurse practitioner on the unit who reviewed
the final article.
Results
Participant characteristics are shown in Table 1.
All were female, with an average age of 42 years,
and five described themselves as other than
White. We identified four themes as important to
nurses’ emotional work in the single-family room
setting: Parents Living on the Unit, Isolation of
Infants in Rooms, Nurses’ Ability to Form Bonds
and Establish Trust With Parents, and Sheltering
Nurses and Parents From Stressful Events on the
Unit. We include direct quotes from each of the
11 participants.
Parents Living on the Unit
Although participants appreciated that parents
could remain close to their infants for an extended
time, some participants felt that not all parents
“use the room like it’s supposed to be used” (i.e.,
narrowly defined to promote infant bonding). In
the interviews, two participants stated that the
single-family room NICU had worsened infant
bonding because some parents, particularly
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Doede, M., and Trinkoff, A. M.
Table 1: Characteristics of the
Participants (N [ 15)
Characteristic n M (range)
Age in years
Age < 30 years 3 opioid. Her anger toward the mother and cyni-
Non-White 5 cism about the infant’s future were evident in her
Bachelor of science in nursing or 15
higher
Full-time 11
Worked some or only nights 8
Years as a registered nurse
> 10 years of NICU experience 8 members with restraining orders that restricted
Open-bay layout experience 11
adolescent parents, were able to do other things
while on the unit besides engaging with their in-
fants and nursing staff. “We have people who
come in who live there 24/7 and they barely even
have any interaction with their baby . they’re just
doing other things. Like sleeping or watching TV,
so I don’t know.” Another participant commented
the following:
They tend to have the environment very
noisy, which interrupts the baby’s well-
being. And they don’t want to be told
what to do. . It’s a teenage issue. They
like to sleep late in the mornings, so when
you turn the light on to assess the baby and
do what you need to do, they get angry
sometimes.
Although the staff members at this setting have
always cared for low-income populations, parents
living on the unit meant that participants were
more exposed to the daily stressors of poverty
that might be unfamiliar to them. More than one
participant commented that parents lived on the
unit because the environment was preferable to
their own homes, “They’re warm when it’s cold.
They’re cool when it’s hot.”
In addition, parents living on the unit meant that
participants were more exposed to one of the
most challenging aspects of their work: caring for
parents who struggled with substance use dis-
orders and infants in opiate withdrawal. Partici-
pants also worried about infants’ home
environments on discharge, “They have lives
outside of this hospital that we can’t even
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RESEARCH
imagine.” Another participant mentioned that she
Nurse felt she didn’t have the necessary communication
skills “to deal with [addiction] situations like that
because I’ve never been in situations like that.”
During direct observation, a participant was car-
43 (22–60)
ing for an infant who was withdrawing from an
tone and language. One participant stated, “I still
have a really hard time . with the withdrawing
babies. That can be really hard on me, especially
depending on how the parents are.”
Parents living on the unit also led to safety con-
17 (1–39)
cerns, especially regarding parents or family
visitation. One participant who previously worked
in the open-bay NICU mentioned that safety was
more problematic in the single-family rooms
because parents were not easily visible to NICU
staff.
It feels like we have more issues in the
single-family rooms. . I think they feel like
they have privacy, so maybe some things
come out. Maybe arguments get taken
further than they would in the open . if
everyone could see them.
Most participants cited the need for increased
security presence and availability on their unit or
expressed fearfulness about violent situations.
One participant related the story of a disagree-
ment that led to a violent outburst, “A dad hit a
mom in the room while the mom had the baby.”
Another mentioned having to move a mother and
infant to a more visible room because she over-
heard the mother shouting at the infant.
Isolation of Infants in Rooms
Infants with few or shorter visits from parents
may be alone in private rooms for long periods.
Per participant report, parents might not be
present because the family lives far away, both
parents work, they have other small children,
and/or the mother has a substance use disorder.
Participants noted that infants without parents at
the bedside tended to get more nurse visitors.
Certainly, nurses were observed holding infants
for long periods of time, especially during
feedings. During interviews and conversations
during observation, participants noted that they
had a “hard time” with the isolation of infants
who did not have frequent parent visits, espe-
cially when infants were older and more medi-
cally stable.
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The single-family room layout increased and decreased
emotional work for nurses.
From observational data, about one third to one
half of the infants on the unit were alone in the
room at any given time. It was not unusual to
observe an infant alone in an empty room at the
end of the hall crying and out of hearing range. In
one instance, a woman approached the nurses’
station to let them know the infant in the next room
was crying. Participants who worked in an
open-bay unit recalled the ease and comfort of
managing infants who did not receive many visits.
I think it [open bay] was a benefit for the
babies because . if we had a stable pa-
tient [who] needed to be held or cradled,
we would walk them around . now you
can’t do that. I would never bring a baby
into [another baby’s] room but in an open
area, if I’m walking and holding this baby,
we would go visit [other babies] and say
hello . you felt close, it felt like home.
Nurses’ Ability to Form Bonds and
Establish Trust With Parents
Privacy created by the single-family room setting
also promoted positive emotions in participants.
One participant felt strongly that the single-family
room layout was beneficial because “it allows us
to be closer to providing true, family-centered
care.” Indeed, nurses were observed sitting
down and talking to parents for up to 30 minutes.
These interactions had the appearance of a nurse
home visit and were unhurried and uninterrupted.
Multiple participants brought up the importance
of forming trust and bonds with parents.
A lot of our families are young parents or
have a lot of different social issues, whether
it’s drugs or domestic violence. . I think
some people just write it off. . But I kind of
step back from it and like to understand
what they’re going through, like they didn’t
just choose to do that. Something is going
on in their life. Maybe they really just need
someone to listen to them.
When participants were able to build trust suc-
cessfully, they tied this success to their sense of
accomplishment, particularly as it related to their
work with parents with social issues. “But I just
feel . accomplished when I can like make that
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Nurses’ Emotional Work in a Single-Family Room NICU
bond with those parents . I feel like I have to get
in and I have to build that trust and it feels good.”
Sheltering Nurses and Parents From
Stressful Events on the Unit
The single-family room layout allowed partici-
pants and parents to experience difficult or
emotional situations out of the view of other par-
ents or health care providers. For instance, par-
ents could privately experience joyful events,
such as discharges to home, or adverse events,
such as an unexpected change in an infant’s
prognosis, grief over a loss, or disagreements
between parents. In contrast, participants with
previous open-bay experience described
concern in that setting about “sheltering the other
parents” from an environment that could some-
times feel emotionally turbulent and where par-
ents experienced most events in full view of
others. Because of the lack of privacy in the
open-bay unit, nurses were sometimes forced to
ask parents to leave their infant’s bedside to give
other parents privacy. Some nurses also felt that it
might be unnerving for parents in open-bay lay-
outs to see how hard the nurses are working, “I’ve
always believed that a family member, a parent
especially, should never know how busy we are,
how stressed we are. They shouldn’t know what’s
going on in the unit. We should protect them from
that.”
Sheltering also referred to the nurse. Participants
were sometimes observed in unoccupied rooms
sitting quietly, reading, using phones, or talking
quietly with coworkers. This seemed to be related
to the need for respite and private space.
That’s actually something I kind of like
about the fact that we have private rooms.
That people don’t always have to see you
all day long. Like if you don’t want to be
seen, then you can be at your patient’s
bedside . if I’m just like really tired. If I’m
just really done and I’m really tired and I
don’t want to talk to grown-ups.
Discussion
The NICU is an emotionally demanding work-
place for nurses regardless of how it is config-
ured. We suggest that unit layout interacts with
organizational rules (e.g., unrestricted parental
visiting), job characteristics (e.g., frequency of
interaction with others), and a nurse’s interper-
sonal skills to magnify or diminish these demands
and thereby influences the level of emotional work
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Doede, M., and Trinkoff, A. M.
(see Figure 1). Privacy provided by walls, doors,
and long corridors elicited negative and positive
emotions in participants.
The private, single-family room setting and unre-
stricted visitation policies for parents meant that
some parents lived on the unit. This increased the
frequency of nurse interactions with parents,
including parents who were less engaged with
their infants and experienced poverty, housing
insecurity, addiction, and family violence. These
issues created additional emotional demands on
participants. On the other hand, participants also
cared for infants who received few visits and were
often alone in private rooms. Participants
expressed negative emotions in response to both
situations, which led them to perform stressful,
emotional work and could drive burnout (Huynh
et al., 2008). Occupational stress was particu-
larly evident when participants witnessed phys-
ical violence or were verbally harassed by
parents. Although these instances were relatively
rare, they were of great concern to the
participants.
Privacy allowed participants to shelter parents
and themselves from the chaos of the unit, which
was an emotional relief. Participants expressed
positive feelings of personal accomplishment in
response to their improved ability to form trust
and bonds with parents because of the single-
family room setting. Their interpersonal skills,
especially their abilities to establish bonds with
parents who faced multiple stressors, were
important to establish participants’ comfort in
working with parents in private rooms. These
positive emotions decreased emotional work and
the drivers of burnout (see Figure 1).
Other researchers have noted that the most
challenging interactions for NICU staff are related
to interacting with parents. Friedman, Friedman,
Colin, and Martin (2017) found that more than
half of NICU staff reported high likelihoods of
challenging interactions with parents who suf-
fered from substance use disorders or were
involved with child protective services; more than
one third reported a high likelihood of challenging
interactions if parents were young or if domestic
abuse was involved. The extended isolation and
lack of social activity that parents may experience
on the single-family room unit and the stress and
uncertainty of having an infant in the NICU may
exacerbate these family tensions. We found that
participants’ inability to easily see into patient
rooms on the single- family unit seemed to allow
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these tensions to escalate. Perhaps when parents
are aware that they cannot be seen or overheard,
they are more likely to demonstrate behavior that
would be unacceptable in an open unit.
Negative emotions related to infants’ isolation in
single-family rooms could be reflective of partic-
ipants’ concerns that isolation could lead to
developmental issues for the infants. Re-
searchers suggested that infants’ lack of expo-
sure to meaningful language in single-family room
NICUs can negatively affect neurodevelopment
by 18 months of age (Pineda et al., 2017; Pineda
et al., 2014). Poor infant development exacer-
bated by poverty and lower levels of maternal
education (Vohr et al., 2017) could be mitigated
by maternal involvement, which is associated with
improved developmental outcomes despite NICU
type (Lester et al., 2016). Clearly, support for
healthy preterm infant development is a complex
undertaking that might be addressed through
encouragement to mothers to be actively verbal
in their interactions with their infants (Welch et al.,
2015).
The participants’ ability to shelter themselves and
parents on the single-family room unit may relieve
stress for both parties. Researchers have
suggested that single-family room layouts protect
parents and nurses from vicarious noise and
trauma and from the grief and sadness of other
parents (Beck, Cusson, & Gable, 2017; Robson,
MacMillan-York, & Dunn, 2016). Cricco-Lizza
(2014) and Robson et al. (2016) noted the “on-
stage” feeling of the open-bay NICU for parents
and nurses.
Nurse burnout could be reduced by feelings of
personal accomplishment with parents, as artic-
ulated by study participants who bonded with
parents. Helping infants, empowering parents,
engaging socially, and professional pride were
found to buffer the negative components of the
work of nurses (Einarsdottir, 2012). Hogan et al.
(2015) found that nurses in open-bay settings
significantly improved their scores on the per-
sonal accomplishment subscale of the Maslach
Burnout Inventory after moving to single-family
room layout, perhaps because nurses were bet-
ter able to build relationships and thus tailor their
care for individual infants and their parents.
Limitations
Our study had several limitations. First, grand tour
and direct observations did not occur during the
night from 11 p.m. to 7 a.m., so we could have
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NICU nurses who plan to convert open-bay settings to
single-family rooms should consider ways to maximize
visibility and maintain privacy.
missed an opportunity to better frame the be-
haviors of adolescent parents who were noted as
disengaged during morning care. In addition,
interviewing and observing only currently
employed nurses raises the concern of selection
bias because nurses who were highly dissatisfied
with the single-family room layout may have left
for other settings, which left nurses who preferred
working in the single-family room layout (Fiske,
2018). Furthermore, single-family room NICUs
differ in construction and layout, so the findings
about visibility and privacy in this study may not
apply to other NICUs with single-family rooms.
Finally, data were collected only by the primary
author. Although A.M.T. and D.W. were consulted
during data analysis and viewed transcripts and
audit trails, they were not present during data
collection. Participant validation and triangulation
of data sources should reduce these concerns.
Implications
We suggest several points for NICU staff to
consider. First, the increased presence of parents
in the NICU offers an enormous opportunity for
nurses to engage with vulnerable families, an
undeniable benefit of the single-family room
layout. The time spent together could include
teaching bonding and infant interaction, espe-
cially for first-time parents. Despite this, lack of
visibility of all infants and parents on the unit may
lead to unsafe situations because nurses are
unable to fully observe parents’ behaviors. The
staff of NICUs that are converting to single-family
rooms should consider ways to maximize visibility
while maintaining privacy, such as windowed
doors or panels or a configuration with two cor-
ridors and a nurses station between to maximize
visibility (Catrambone, Johnson, Mion, & Minnick,
2008). The Occupational Safety and Health
Administration’s (2016) most recent guidelines
on the prevention of violence in hospitals indicate
that unit layouts that block sight lines are a risk
factor for job-related violence. Increasing visibility
into rooms also may relieve concerns about
isolation for infants who receive fewer visits.
NICU administrators might consider the addition
of peer counselors and peer support activities.
Peer counselors provide invaluable mother-to-
mother emotional support (Rossman, Greene, &
290 JOGNN, 49, 283–292; 2020. https://doi.org/10.1016/j.jogn.2020.03.001
Nurses’ Emotional Work in a Single-Family Room NICU
Meier, 2015) and are accepted as an important
source of workload assistance by NICU staff
(Rossman, Engstrom, & Meier, 2012). Peer sup-
port can be tailored to the specific needs of
parents and has been effective to reduce sub-
stance use and relapse rates and improve re-
lationships between patients and providers
(Eddie et al., 2019). NICU-based parenting sup-
port classes for mothers in recovery could bring
mothers together, increase their confidence in
caring for their infants (Blunt, 2009), and provide
valuable time for socialization outside of infants’
rooms.
Neonatal nurses may adapt to working in private
rooms more easily if they feel more confident in
communicating with parents from different cul-
tures or ethnicities than their own or who experi-
ence social and economic challenges. Cultural
competence training for nurses has been recog-
nized as an essential component in reducing
health care disparities for more than a decade
(American Association of Colleges of Nursing,
2008). Although the inclusion of cultural compe-
tence training in nursing education is an impor-
tant first step (Long, 2012), practicing NICU
nurses would benefit from a variety of continuing
education offerings that emphasize the provision
of care for diverse populations (Heitzler, 2017).
Improved competency in this area could increase
nurses’ sense of effectiveness and improve nurse
and parent satisfaction.
Last, nurses also can benefit from peer support.
Even occasional opportunities to share workplace
experiences can bolster emotional well-being
(Lorraine, 2016) and serve as a venue in which
to share strategies for working with vulnerable
families. All of these suggestions are appropriate
for NICUs in general but become more important
as single-family room layouts increase nurses’
interactions with parents but limit interactions
among parents.
Conclusion
Care should be taken in NICU design because
unit layout can affect the emotional work of
nurses. Single-family room NICUs may introduce
additional emotional demands for nurses as the
frequency of solo interactions with parents in-
creases. At the same time, some infants may be
isolated from human interactions if parents are
unable to visit, and nurses are only in the room for
limited periods. However, single-family room
NICUs may reduce emotional demands for
nurses by providing an optimal private
http://jognn.org
Doede, M., and Trinkoff, A. M.
environment to build trust and bonds with parents
and by allowing nurses to shelter parents and
themselves from chaotic or stressful environ-
ments. Understanding these nuances can help
nurses as they prepare to transition from an open-
bay to a single-family room layout and assist
those who already work in single-family room
settings to identify ways to improve the practice
environment and family-centered and infant
developmental care.
Acknowledgment
Partially funded by the Maryland Higher Educa-
tion Council New Nursing Faculty Fellowship. The
authors acknowledge the contributions of Debra
Wiegand, PhD, RN, FAAN, who died before the
completion of this manuscript.
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