Acta Pædiatrica ISSN 0803-5253
EDITORIAL DOI:10.1111/apa.12566
The role of single-patient neonatal intensive care unit rooms for preterm infants It has been suggested that a single-room neonatal intensive care unit (NICU) design has the potential to decrease stressful stimuli, improve parent infant interactions and prevent nosocomial infection. A recent systematic review supported these assumptions, by concluding that providing families with single rooms led to superior patient care and parental satisfaction (1). However, as well as highlighting positive parental experiences, the review also raised concerns from healthcare personnel about greater workload, reduced visibility of infants and reduced communication between staff. The single-room design has, without doubt, had a major impact on infant outcome. However, it is important to consider the impact of other factors before this design is perceived as evidence-based practice. By the 1950s, James Robertson and John Bowlby had already identified that separating infants and parents at an early stage could lead to adverse infant development. Their shocking results about the distress that could be caused by separating young patients from their parents during a short hospital stay acted as a catalyst for healthcare changes. New recommendations were suggested in many developed countries, such as allowing parents to stay in hospital with their children and providing accommodation for parents. Thus, the role of families in promoting the health and well-being of their children was established. Although many years have passed, and parents’ reactions have been well documented, these recommendations are not yet accepted as standard neonatal care. An infant’s admission to the NICU not only causes anxiety, depression and stress, it also leads to an alteration in the parental role, which adversely affects the early bonding process, maternal sensitivity to the baby’s cues and interaction between the mother and the infant (2). These results should be understood in terms of the broad consensus that child development is a result of the interaction between the child’s biological conditions and environmental factors. An infant’s developmental vulnerability, due to preterm birth, and its subsequent high risk of neuropsychological impairments, has mainly been explained by gestational age and birth weight. However, these associations appear to be confounded by other factors, such as socioeconomic class and IQ (3) and maternal distress and social support (4). The explanations regarding the causal relationship remain questionable, because maternal and social background factors are recognised to increase the risk of preterm birth, while improved infant outcomes have been associated with intervention programmes that focus on parent infant interaction. Therefore, it is possible that paying more attention to the parents’ needs during the infant’s stay at the NICU might result in improved cognitive outcome. Also, communication
462
between healthcare staff and parents has the potential to reduce stress and make interactions with the baby possible (5). This philosophy of care, which aims to help parents to actively participate in the care of their child, is often referred to as a family-centred care (FCC) and has been explained as a set of guiding principles (6). Several key aspects have been recognised in addition to the important mechanisms, such as support from staff and the physical NICU design. Some of the most important cornerstones are parents taking part in decision-making and their presence and participation in caregiving. Even if a single-room design does not guarantee FCC, it may provide facilities that enable parents to be present from admission to discharge, to participate in the care of their infant and to increase their confidence long before discharge. The duration of this parental presence may also increase their exposure to physical contact and satisfaction with parenting. Parental sensitivity and responsiveness to the infants’ physiological and emotional cues have been associated with nursing methods such as the Newborn Individualised Development Care and Assessment Program (NIDCAP), skin-to-skin care and breastfeeding support and promotion, all important parts of FCC. Investigating the effect of a NICU environment on an infant’s development is complex. In addition to physical facilities, both parents’ characteristics and staff attitudes represent important aspects of the infant’s environment. In a randomised trial carried out in Stockholm, we showed that providing single rooms and enabling parents to be present throughout their infant’s hospital stay had a positive effect on the child’s health, in terms of a shorter hospital stay, lower risk of moderate-to-severe bronchopulmonary dysplasia and a positive impact on the mother–infant relationship at discharge (7,8). Family-centred care was used as the philosophy of care in both groups, although the extent to which it was practised was different because of the physical environment. The intervention group was admitted to a unit with separate rooms for all families, including beds for both parents and a private bathroom. At least one parent was expected to be with the baby around-the-clock. An essential part of the strategy was the initial parental support associated with newly admitted and very unstable infants, who were cared for in a four-bed room. At this stage, the staff took full responsibility for infant care, but the parents were close by to support the infant’s emotional needs. The parents became primary caregivers when the infant reached a stable state and was moved into the single family room. All rooms had equipment for supplementary oxygen and nasal continuous positive airway pressure. Daily caring and surveillance of the infant was handed over to the parents,
ª2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 462–463
Editorial
according to their increasing knowledge, skills and confidence. The staff kept an eye on the infant’s state using wireless telemetric monitoring. Both the mothers and fathers were encouraged to play an active role in providing essential support to the infant and were seen as members of the caring team. All the parents who were present were encouraged to participate in medical rounds, in decisionmaking and during medical procedures. They were never asked to step out of the room, but could choose to do so if they wanted. Most mothers initiated breastfeeding and started semi-demand feeding and gavage feeding. Siblings were welcome after consultation with staff members. The infants in the control group had daily contact with at least one of the parents. All parents in Sweden are covered by the parental allowance regulation, which provides financial support during temporary parental leave if their child is seriously ill, corresponding to 80 per cent of earnings up to a defined limit. Unfortunately, there was no follow-up regarding child development in this trial. Roberta G Pineda and coworkers (9) recently contributed to our knowledge about the association between the care environment and infant development, by suggesting that altered cerebral development and lower language scores were associated with single rooms in the NICU. A total of 136 infants born ≤30 weeks’ gestation were recruited. In total, 56 of these infants were included in the analysis of cerebral maturation at term age, and 86 of the infants were included in the development assessment at 2 years of age using the Bayley Scales of Infant and Toddler Development, Third Edition. All infants were admitted to a 75-bed, level III NICU, which included both open ward beds and private rooms. The allocation to one of these environments was based on space and staffing availability, not on a random distribution. However, there were no major differences between the groups when it came to reported factors such as infant background, sociodemography and infant morbidity. Unfortunately, this article did not include any information on the extent and methods of parental support during the hospital stay. In an earlier publication, the same author presented the duration of parental presence for 81 infants at the same study setting (10). The results revealed that the parents of infants in single rooms spent more average hours on the unit (25.5 h per week) compared with the parents of infants in the open-bay area (16.8 h per week). These findings represent a very low visit rate in both groups, but are consistent with previous findings about positive experiences associated with improved privacy in a single family room, compared with the open-bay design (1). The authors should be commended for their important contribution, by providing new knowledge about the association between the care environment and infant development. However, the study design means that the results must be interpreted with some caution. Other factors associated with the single-patient room environment might also be relevant. For example, it is reasonable to assume that the privacy provided by single rooms might also increase the risk of parents having less contact with healthcare staff. A lack of communication may have implications for the child’s behavio-
Editorial
ural and emotional symptoms, as well as their cognitive development. Ordinary ‘chatting’ has been found to serve as the strategy and the process through which positive interactions are initiated, maintained and enhanced (5). In addition, the early dyadic pattern of mother–infant interactions has been associated with language development (2). The impact of the total environmental experience on infant outcome needs further examination. Facilitating early parent infant interactions is still a viable motive for choosing a single family room design. And Pineda et al. have made an important contribution to the debate, by providing more evidence showing that changes in the physical environment also require new approaches to nursing care.
€ Annica Ortenstrand ([email protected]) Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
References 1. Shahheidari M, Homer C. Impact of the design of neonatal intensive care units on neonates, staff, and families. J Perinat Neonatal Nurs 2012; 26: 260–6. 2. Forcada-Guex M, Pierrehumbert B, Borghini A, Moessinger A, Muller-Nix C. Early dyadic patterns of mother-infant interactions and outcomes of prematurity at 18 months. Pediatrics 2006; 118: e107–14. 3. Eriksen HL, Kesmodel US, Underbjerg M, Kilburn TR, Bertrand J, Mortensen EL. Predictors of intelligence at the age of 5: family, pregnancy and birth characteristics, postnatal influences, and postnatal growth. PLoS ONE 2013; 8: e79200. 4. Miceli PJ, Goeke-Morey MC, Whitman TL, Kolberg KS, Miller-Loncar C, White RD. Brief report: birth status, medical complications, and social environment: individual differences in development of preterm, very low birth weight infants. J Pediatr Psychol 2000; 25: 353–8. 5. Guillaume S, Michelin N, Amrani E, Benier B, Durrmeyer X, Lescure S, et al. Parents’ expectations of staff in the early bonding process with their premature babies in the intensive care setting: a qualitative multicenter study with 60 parents. BMC Pediatr 2013; 13: 18. 6. Gooding JS, Cooper LG, Blaine AI, Franck LS, Howse JL, Berns SD. Family support and family-centered care in the neonatal intensive care unit: origins, advances, impact. Semin Perinatol 2011; 35: 20–8. € € m EB, Sarman I, Akerstro €m 7. Ortenstrand A, Westrup B, Brostro S, Brune T, et al. The Stockholm Neonatal Family Centered Care Study: effects on length of stay and infant morbidity. Pediatrics 2010; 125: e278–85. € € relius E, Brostro € m EB, Westrup B, Sarman I, Ortenstrand 8. Mo A. The Stockholm Neonatal Family-Centered Care Study: effects on salivary cortisol in infants and their mothers. Early Hum Dev 2012; 88: 575–81. 9. Pineda RG, Neil J, Dierker D, Smyser CD, Wallendorf M, Kidokoro H, et al. Alterations in brain structure and neurodevelopmental outcome in preterm infants hospitalized in different neonatal intensive care unit environments. J Pediatr 2014; 164: 52–60. 10. Pineda RG, Stransky KE, Rogers C, Duncan MH, Smith GC, Neil J, et al. The single-patient room in the NICU: maternal and family effects. J Perinatol 2012; 32: 545–51.
ª2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 462–463
463
EDITORIAL DOI:10.1111/apa.12566
The role of single-patient neonatal intensive care unit rooms for preterm infants It has been suggested that a single-room neonatal intensive care unit (NICU) design has the potential to decrease stressful stimuli, improve parent infant interactions and prevent nosocomial infection. A recent systematic review supported these assumptions, by concluding that providing families with single rooms led to superior patient care and parental satisfaction (1). However, as well as highlighting positive parental experiences, the review also raised concerns from healthcare personnel about greater workload, reduced visibility of infants and reduced communication between staff. The single-room design has, without doubt, had a major impact on infant outcome. However, it is important to consider the impact of other factors before this design is perceived as evidence-based practice. By the 1950s, James Robertson and John Bowlby had already identified that separating infants and parents at an early stage could lead to adverse infant development. Their shocking results about the distress that could be caused by separating young patients from their parents during a short hospital stay acted as a catalyst for healthcare changes. New recommendations were suggested in many developed countries, such as allowing parents to stay in hospital with their children and providing accommodation for parents. Thus, the role of families in promoting the health and well-being of their children was established. Although many years have passed, and parents’ reactions have been well documented, these recommendations are not yet accepted as standard neonatal care. An infant’s admission to the NICU not only causes anxiety, depression and stress, it also leads to an alteration in the parental role, which adversely affects the early bonding process, maternal sensitivity to the baby’s cues and interaction between the mother and the infant (2). These results should be understood in terms of the broad consensus that child development is a result of the interaction between the child’s biological conditions and environmental factors. An infant’s developmental vulnerability, due to preterm birth, and its subsequent high risk of neuropsychological impairments, has mainly been explained by gestational age and birth weight. However, these associations appear to be confounded by other factors, such as socioeconomic class and IQ (3) and maternal distress and social support (4). The explanations regarding the causal relationship remain questionable, because maternal and social background factors are recognised to increase the risk of preterm birth, while improved infant outcomes have been associated with intervention programmes that focus on parent infant interaction. Therefore, it is possible that paying more attention to the parents’ needs during the infant’s stay at the NICU might result in improved cognitive outcome. Also, communication
462
between healthcare staff and parents has the potential to reduce stress and make interactions with the baby possible (5). This philosophy of care, which aims to help parents to actively participate in the care of their child, is often referred to as a family-centred care (FCC) and has been explained as a set of guiding principles (6). Several key aspects have been recognised in addition to the important mechanisms, such as support from staff and the physical NICU design. Some of the most important cornerstones are parents taking part in decision-making and their presence and participation in caregiving. Even if a single-room design does not guarantee FCC, it may provide facilities that enable parents to be present from admission to discharge, to participate in the care of their infant and to increase their confidence long before discharge. The duration of this parental presence may also increase their exposure to physical contact and satisfaction with parenting. Parental sensitivity and responsiveness to the infants’ physiological and emotional cues have been associated with nursing methods such as the Newborn Individualised Development Care and Assessment Program (NIDCAP), skin-to-skin care and breastfeeding support and promotion, all important parts of FCC. Investigating the effect of a NICU environment on an infant’s development is complex. In addition to physical facilities, both parents’ characteristics and staff attitudes represent important aspects of the infant’s environment. In a randomised trial carried out in Stockholm, we showed that providing single rooms and enabling parents to be present throughout their infant’s hospital stay had a positive effect on the child’s health, in terms of a shorter hospital stay, lower risk of moderate-to-severe bronchopulmonary dysplasia and a positive impact on the mother–infant relationship at discharge (7,8). Family-centred care was used as the philosophy of care in both groups, although the extent to which it was practised was different because of the physical environment. The intervention group was admitted to a unit with separate rooms for all families, including beds for both parents and a private bathroom. At least one parent was expected to be with the baby around-the-clock. An essential part of the strategy was the initial parental support associated with newly admitted and very unstable infants, who were cared for in a four-bed room. At this stage, the staff took full responsibility for infant care, but the parents were close by to support the infant’s emotional needs. The parents became primary caregivers when the infant reached a stable state and was moved into the single family room. All rooms had equipment for supplementary oxygen and nasal continuous positive airway pressure. Daily caring and surveillance of the infant was handed over to the parents,
ª2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 462–463
Editorial
according to their increasing knowledge, skills and confidence. The staff kept an eye on the infant’s state using wireless telemetric monitoring. Both the mothers and fathers were encouraged to play an active role in providing essential support to the infant and were seen as members of the caring team. All the parents who were present were encouraged to participate in medical rounds, in decisionmaking and during medical procedures. They were never asked to step out of the room, but could choose to do so if they wanted. Most mothers initiated breastfeeding and started semi-demand feeding and gavage feeding. Siblings were welcome after consultation with staff members. The infants in the control group had daily contact with at least one of the parents. All parents in Sweden are covered by the parental allowance regulation, which provides financial support during temporary parental leave if their child is seriously ill, corresponding to 80 per cent of earnings up to a defined limit. Unfortunately, there was no follow-up regarding child development in this trial. Roberta G Pineda and coworkers (9) recently contributed to our knowledge about the association between the care environment and infant development, by suggesting that altered cerebral development and lower language scores were associated with single rooms in the NICU. A total of 136 infants born ≤30 weeks’ gestation were recruited. In total, 56 of these infants were included in the analysis of cerebral maturation at term age, and 86 of the infants were included in the development assessment at 2 years of age using the Bayley Scales of Infant and Toddler Development, Third Edition. All infants were admitted to a 75-bed, level III NICU, which included both open ward beds and private rooms. The allocation to one of these environments was based on space and staffing availability, not on a random distribution. However, there were no major differences between the groups when it came to reported factors such as infant background, sociodemography and infant morbidity. Unfortunately, this article did not include any information on the extent and methods of parental support during the hospital stay. In an earlier publication, the same author presented the duration of parental presence for 81 infants at the same study setting (10). The results revealed that the parents of infants in single rooms spent more average hours on the unit (25.5 h per week) compared with the parents of infants in the open-bay area (16.8 h per week). These findings represent a very low visit rate in both groups, but are consistent with previous findings about positive experiences associated with improved privacy in a single family room, compared with the open-bay design (1). The authors should be commended for their important contribution, by providing new knowledge about the association between the care environment and infant development. However, the study design means that the results must be interpreted with some caution. Other factors associated with the single-patient room environment might also be relevant. For example, it is reasonable to assume that the privacy provided by single rooms might also increase the risk of parents having less contact with healthcare staff. A lack of communication may have implications for the child’s behavio-
Editorial
ural and emotional symptoms, as well as their cognitive development. Ordinary ‘chatting’ has been found to serve as the strategy and the process through which positive interactions are initiated, maintained and enhanced (5). In addition, the early dyadic pattern of mother–infant interactions has been associated with language development (2). The impact of the total environmental experience on infant outcome needs further examination. Facilitating early parent infant interactions is still a viable motive for choosing a single family room design. And Pineda et al. have made an important contribution to the debate, by providing more evidence showing that changes in the physical environment also require new approaches to nursing care.
€ Annica Ortenstrand ([email protected]) Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
References 1. Shahheidari M, Homer C. Impact of the design of neonatal intensive care units on neonates, staff, and families. J Perinat Neonatal Nurs 2012; 26: 260–6. 2. Forcada-Guex M, Pierrehumbert B, Borghini A, Moessinger A, Muller-Nix C. Early dyadic patterns of mother-infant interactions and outcomes of prematurity at 18 months. Pediatrics 2006; 118: e107–14. 3. Eriksen HL, Kesmodel US, Underbjerg M, Kilburn TR, Bertrand J, Mortensen EL. Predictors of intelligence at the age of 5: family, pregnancy and birth characteristics, postnatal influences, and postnatal growth. PLoS ONE 2013; 8: e79200. 4. Miceli PJ, Goeke-Morey MC, Whitman TL, Kolberg KS, Miller-Loncar C, White RD. Brief report: birth status, medical complications, and social environment: individual differences in development of preterm, very low birth weight infants. J Pediatr Psychol 2000; 25: 353–8. 5. Guillaume S, Michelin N, Amrani E, Benier B, Durrmeyer X, Lescure S, et al. Parents’ expectations of staff in the early bonding process with their premature babies in the intensive care setting: a qualitative multicenter study with 60 parents. BMC Pediatr 2013; 13: 18. 6. Gooding JS, Cooper LG, Blaine AI, Franck LS, Howse JL, Berns SD. Family support and family-centered care in the neonatal intensive care unit: origins, advances, impact. Semin Perinatol 2011; 35: 20–8. € € m EB, Sarman I, Akerstro €m 7. Ortenstrand A, Westrup B, Brostro S, Brune T, et al. The Stockholm Neonatal Family Centered Care Study: effects on length of stay and infant morbidity. Pediatrics 2010; 125: e278–85. € € relius E, Brostro € m EB, Westrup B, Sarman I, Ortenstrand 8. Mo A. The Stockholm Neonatal Family-Centered Care Study: effects on salivary cortisol in infants and their mothers. Early Hum Dev 2012; 88: 575–81. 9. Pineda RG, Neil J, Dierker D, Smyser CD, Wallendorf M, Kidokoro H, et al. Alterations in brain structure and neurodevelopmental outcome in preterm infants hospitalized in different neonatal intensive care unit environments. J Pediatr 2014; 164: 52–60. 10. Pineda RG, Stransky KE, Rogers C, Duncan MH, Smith GC, Neil J, et al. The single-patient room in the NICU: maternal and family effects. J Perinatol 2012; 32: 545–51.
ª2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 462–463
463
