The Father’s experience in the NICU

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A Family-Centered Care Approach

With advances in neonatal and pediatric intensive care, the survival of hospitalized children has increased. These advances also has increased the length of the average hospital stay and increased health-care costs. Research supports a family-centered care approach in the neonatal intensive care unit (NICU), which promotes parental involvement. The nurse plays an important role in facilitating a healthy environment for the parent and the infant to bond.1,2 Care in the NICU was once focused on the infant’s physical needs, with the family’s psychological needs viewed as secondary. Families in the hospital setting were treated as visitors or attendants. Midway through the 20th century, however, increased attention on child/family separation trauma in hospital settings caused changes in hospital policies that allowed for rooming-in and open visiting hours. This marked the beginning of a family-centered care approach in pediatric health care.4

Family-centered care is an approach to making decisions about children’s health care based on a partnership between the family and members of the health-care team. During the late 1900s, the Surgeon General and the Maternal and Child Health Bureau (MCHB) supported changes in the current practice of family-centered care. In 2003, the American Academy of Pediatrics (AAP) included family-centered care as standard for health care for all children. Family-centered care and patient-centered care appear in Healthy People 2020 as key outcomes for children with special health-care needs.3,4

Despite the support of a family-centered philosophy of care and related policies in institutions that provide care for children, relationships and the care of families at the bedside, in many cases, have not changed accordingly, especially in the critical-care setting. Care has become so complex that professionals believe that they have to protect the infants from their families, which prevents parent-infant bonding and attachment. Parents are not always supported by staff, which increases feelings of stress.3 A lack of understanding of what family-centered care is and a lack of support for its practice result in problems with its implementation. Health-care providers and parents do not know their roles in this practice. There is also a lack of validated research on outcome measures for family-centered care as well as a lack of specific guidelines for its implementation. These issues need to be addressed so that nurses will work in partnership with the parents of hospitalized children.4

Before patient-and family-centered care was implemented as a standard of practice in pediatric healthcare, parental involvement was limited. Parents were viewed as visitors in the NICU and not allowed to participate in the care of the infant. Parental involvement has improved with the use of this approach but it is not implemented properly. Fathers are not equally encouraged to participate in the care of the infant. Parents should be involved in decision making and in the care of the child in the NICU. A patient-and family-centered care approach improves patient and family satisfaction, which may positively affect parenting in the NICU. The primary misunderstanding about patient-and family-centered care involves details of its definition and implementation. Nurses need to be informed about the importance of implementing a patient- and family-centered care approach when caring for the pediatric patient and his or her family in NICU. Mothers and fathers should be viewed as equal partners in parenting.4

The NICU environment is a source of stress for parents and infants. It has increased the survival of premature and sick full-term infant and has increased parental stress, altered the expected parental role and created feelings of separation that may delay parental attachment and bonding. Parents worry about the cost of care and the day to day health progress of their child.5 In the NICU, fathers struggle with working and taking care of the household while supporting the mother. They struggle with assuming these multiple roles which may limit the time they have to visit the NICU. In most cases, if fathers do not feel encouraged and supported by nurses, they will not visit the NICU. Some are willing to be involved but are fearful of holding the fragile infant. Others are reluctant to participate in the care of the infant and are comfortable playing a supportive role because they see the mother as a primary caregiver. Fathers need to be encouraged to visit and participate in the care of their infant in the NICU which will improve parent-infant bonding and attachment and increase parental role confidence.6 Care in the NICU has become so complex that professionals believe that they have to protect the infants from their families, which prevents parent-infant bonding and attachment.7

The mother’s presence can encourage the father’s lack of interaction in the NICU because he sees her as a primary nurturer for the baby. Fathers may stay away from the NICU if their needs for encouragement and support are not met. Their feelings need to be explored by the nurse. Nurses need to teach the fathers positive coping skills and communicate with them and encourage their presence and participation in the care of their infant. Nurses need to encourage fathers to perform infant care tasks such as changing and feeding the infant and encouraging their participation in healthcare decisions.6 Men do not feel like they are a father to their infant unless they are able to touch or hold their infant and have physical or eye contact.8 If fathers are not included in the care of the infant, bonding between father and infant will be affected.9 The father may neglect the needs of the child if he never bonded with the child. When compared with mothers, fathers cope differently with stress and find different aspects of the NICU experience stressful.10 The way they cope with this experience is unknown and needs to be explored. The fathers’ experience of having a hospitalized child has been underreported, and as a result, their experience is poorly understood. Understanding the experience of being a father to an infant in the NICU is important for nurses and other health-care providers so that they may provide appropriate interventions for these individuals.

References
1.Watson, G. Parental liminality: A way of understanding the early experiences of parents who have a very preterm infant. Journal of Clinical Nursing. 2011, 20 (9-10), 1462-71.
2. Lantos, J.D, & Meadow, W.L. Costs and End-of-Life Care in the NICU: Lessons for the MICU? Journal of Law, Medicine and Ethics. 2011, 39(2).
3. McGrath, J. Building relationships with families in the NICU: Exploring the guarded alliance. Journal of Neonatal Nursing. 2001, 15(3), 73-83.
4. Kuo, D. Z., Houtrow, A. J., Arango, P., Kuhlthau, K. A., Simmons, J. M., & Neff, J. M.
Family centered care: Current applications and future directions in pediatric health care. Maternal Child Health Journal. 2011, 16, 297-305.
5.Philip, A. G. The evolution of neonatology. Pediatric Research. 2005, 58(4), 799-815.
6. Feeley, N., Sherrard, K., Waitzer, E., & Boisvert, L.The father at the bedside: Patterns of involvement in the NICU. Journal of Perinatal and Neonatal Nursing. 2013, 27, 72-80.
7. McGrath, J. Building relationships with families in the NICU: Exploring the
guarded alliance. Journal of Neonatal Nursing. 2001, 15(3), 73-83.
8. Lindberg, B., Axelsson , K., & Ohrling, K. Adjusting to being a father to an infant born
prematurely: Experiences from Swedish fathers. Scandinavian Journal of Caring Sciences. 2008, 22(1), 79-85.
9. Garten, L., Maass, E., Schmalisch, G., & Buhrer, C. O father, where art thou? Parental NICU visiting patterns during the first 28 days of life of very low birth-weight infants. Journal of Perinatal and Neonatal Nursing. 2011, 25(4), 342-348
10. Deeney, K., Lohan, M., Parkes, J., & Spence, D. Experience of fathers of babies in intensive care. Pediatric Nursing. 2009, 21(1), 45-47.

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Dr. Jemimah Mitchell-Levy, PhD, ARNP

Dr. Jemimah Mitchell-Levy, PhD, ARNP is a Senior Associate Professor at the Benjamin Leon School of Nursing, Miami Dade College.

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