BACKGROUND AND SIGNIFICANCE
Transitions are a central concept in nursing and have been characterized in the literature as a process of adapting to and experiencing a change involving 1 or more people.1,2 While hospitalized in the neonatal intensive care unit (NICU), infants and their families may undergo multiple types of transitions. These include changes in the infant's health status, adapting to parenting, and the infant's move between rooms on the same unit, units within a hospital, or even between different hospital centers.3 Many of these transitions may occur simultaneously.
However, despite the prevalence of transitions in the NICU, few studies have investigated the perceptions and experiences of families regarding these events.4 The limited research in a NICU context has demonstrated that these experiences can be stressful for parents and that they require support and information from staff at these times.3,5 However, while these studies can provide some insight into what parents perceive as stressful, very few of these studies have specifically investigated factors that impact their perception of the transition.3,4
There are 3 main types of room designs in NICUs. Single family rooms (SFRs) are private rooms with space for 1 infant and their family. In contrast, open wards are large rooms with space for 10 to 50 infants and pods are rooms with 6 to 8 infants each. Recent recommendations concerning NICU architectural design support the need for more research into transitions between room types as some experts have called for units with different types of rooms to be available to care for infants and their families with different needs and at different times during their stay.6,7 As well as changes in room type, these transitions can also involve changes in staffing, level of care and equipment, and may result in additional transition experiences for families. These mixed-room designs can be more affordable and space efficient, as well as ensure that the room type used best suits the needs of families.6,8 However, little research has been conducted on the transitions that arise in mixed-room NICUs, and only a few of these have specifically examined the factors that may affect transitions.3,9
As some NICUs shift to mixed-room designs, it is crucial to better understand the factors affecting parents' perceptions of these transitions in order to develop strategies to help them adjust. As such, this study examined parents' perceptions of factors affecting the transition of their infant from a 6-bed pod to an SFR in a mixed-room design NICU.
Purpose
The goal of this study was to examine parent perceptions of factors affecting the transition from a 6-bed pod to SFR in a mixed-room design NICU.
What This Study Adds
* Framing the transition in a positive way by linking it to an indication that the infant's condition is improving and how the transition may benefit the family can help families cope with the transition.
* Parents have specific informational needs for transitions, and these may be impacted by their past experiences.
* Parental coping can be strengthened through provision of support from staff.
METHODS
The original study described parents' overall perceptions of the transition from a 6-bed pod to SFR using a qualitative descriptive design.10 This secondary analysis sought to describe parents' perceptions of the factors that affected their transition. A qualitative descriptive design was employed as it allows for descriptions of participant experiences using their own words.11 Ethics approval was obtained from the hospital where the study took place (Federal Assurance Number 0796).
Setting and Sample
This study was conducted at a level III NICU in Montreal, Canada. This NICU has a mixed-room design where the same staff work in all areas, but infants are moved to different room types throughout their stay. Infants are first admitted to 1 of 3 critical care pods and then moved to 1 of 2 intermediate care pods once they no longer require oxygen therapy. Each pod has space for 6 infants, and a physiologic monitor is visible above each bed space. The nurse-to-patient ratio in both critical care and intermediate pods is 1 nurse to 1 to 3 infants depending on infant acuity. Once the infants are approaching discharge, they are moved to an area with eight SFRs. Here, a central monitoring system is used to monitor the infants. Each room also has a small window looking out to the hallway, where staff can observe the infants. In this area, the nurse-to-patient ratio is 1:4 and to prepare for discharge, parents are expected to take on more of an active role in their infant's care including staying overnight if possible. Although infants are often transferred at least once between the critical care and intermediate pods, the move to an SFR represents a significant change in terms of layout, staffing, visibility of staff and others, and expectations of parents. Transitions occur between the different areas or levels of care when an infant has met the criteria for the new area and according to the staffing needs of the unit. Although informal conversations between staff and parents do occur, there is no protocol or standard written information provided to parents about the transfer from a pod to an SFR.
For this study, participants were eligible if they (1) had an infant who was hospitalized in a pod for at least 1 week, (2) had been in an SFR for at least 2 days, (3) were present on the unit for a minimum of 5 hours a week, and (4) spoke French or English. Parents were excluded if their infant was (1) to be palliated or to be placed in foster care, or (2) was diagnosed with a grade 4 intraventricular hemorrhage or gene disorder. A minimum of 2 days was used as an eligibility criterion as this was considered to give parents sufficient time to experience the new space.
Purposive sampling was employed to ensure a wide range of gestational ages at birth of the infants and so while all parents who met eligibility criteria were initially approached, after several interviews were conducted only some parents whose infants fell into different categories of prematurity were considered. Targeted recruitment was also used to ensure adequate representation of both fathers and mothers in the study sample.
Procedure
Data were collected from September 2020 until February 2021. After a brief description of the study from the designated clinicians on the unit, potential participants were provided with a copy of the consent form and asked whether they would agree to be contacted by the research team. Given the COVID-19 pandemic, the research team obtained verbal consent by telephone. Following this, the first and second authors conducted semistructured interviews also via telephone. Interviews lasted between 30 and 45 minutes and were audio-recorded using an external recorder. Interviews began by asking parents to describe their general experience. Questions were also asked more specifically about what helped during the transition and what made the transition more difficult in order to understand factors that shaped their transition experience. For example, the participants were asked, "What, if anything, helped you with this transition from a pod to a single-family room for parents?" and "What, if anything, made it more difficult?" As data collection and analysis were conducted simultaneously, specific probes were added in subsequent interviews to further elicit and clarify codes noted in previous interviews. Information was also collected about the infants from the medical record and participant data were gathered via a demographic questionnaire, which was completed prior to commencement of the interview.
Data Analysis
Interviews were transcribed verbatim prior to the analysis. The data were analyzed using inductive content analysis.12 Coding was done using the qualitative analysis software Dedoose. The first 3 transcripts were read and open coded by each of the authors and discussions were held as a group. The authors read the transcripts scanning for meaning units pertaining to the question of what factors parents considered influenced their transition experience and codes were assigned to transcript segments linked to that question. Although this analysis was done specifically to investigate factors, entire transcripts were examined and not just the responses to these specific interview questions. Subsequent interviews were open coded by the first 2 authors who read each several times to ensure that all aspects were well represented. Eventually, these open codes were then grouped into broader categories of factors. During the abstraction process, these categories were further refined through discussions among the whole group.
RESULTS
Participants
There were 17 participants in this study of whom 7 were fathers and 10 were mothers. Four couples were interviewed but all were interviewed separately. Men had an average age of 38 years (SD = 5.2), whereas women had an average age of 32.9 years (SD = 3.4). All parents had an infant who had been born premature and initially had respiratory distress syndrome. In addition, 5 of the infants were also considered to have been intrauterine growth-restricted, 5 had bronchopulmonary dysplasia, and 4 had a 1-sided grade 1 intraventricular hemorrhage during their stay. Two parents had previous NICU experience with an older child. The infants had been hospitalized for an average of 63.3 days with a range of 23 to 115 days at the time of recruitment (SD = 27). All infants but 1 had at least 1 transfer from one of the intensive care pods to an intermediate care pod. One infant had been additionally transferred twice between intensive care pods due to unit needs related to the COVID-19 pandemic. Participants were interviewed between 4 and 13 days after their transition, with an average of 7.9 days (SD = 2.8), including 4 parents who had already been discharged home with their infant at the time of their interview. Three of those who had been discharged home were home less than 1 day before their interview; however, one had been home for 10 days. See Table 1 for parent and infant characteristics.
Major Categories
Four categories of factors shaped parents' transitions: (1) the framing, timing, and comprehensiveness of information provided by staff regarding the transition; (2) parents' perception of advantages and disadvantages of the new space; (3) parents' own well-being and quality of support from staff; and (4) parents' previous NICU and parenting experience.
Framing, Timing, and Comprehensiveness of Information Provided by Staff Regarding Transition
The way the SFR area was described by staff to parents impacted their transition. Framing by staff of the transition as a "good sign" of the infant's improved health status was viewed as having a positive impact on their transition. Similarly, when staff framed or presented the transition as "a step closer to discharge," parents found this encouraging and described it as facilitating their transition. As one father remarked, "Of course we hoped to move towards the [SFRS] because [healthcare staff] kept telling us it is for babies who are almost ready to go home." Parents did not recount any examples of staff highlighting negative aspects of the transition.
The amount and clarity of the information provided about the SFR also played a role. For example, most felt that it would have been important to know in advance expectations for them in this new area, criteria for the transfer decision, how the monitors worked, and staff-ratio changes. However, parents felt that information provided was dependent on the staff caring for their infant and for some parents information that they felt was necessary was not provided. When this occurred, some parents were comfortable following up with staff for needed information after the transfer; however, others expressed that they would have preferred not to have to ask staff for information. For example, one mother noted, "It would have helped to have someone ... to not have to think of everything myself ..." As such, she considered that a more formalized process, including written documents with routine questions, would have helped ensure that they had all the information they needed.
The timing of the information provided by staff was also key. Nearly all parents felt that having information about the transition prior to the event, as well as advance notice that the transition was going to occur, facilitated their transition. In addition, being offered a tour of the area by nurses prior to being moved was also viewed positively by parents who received one as it gave parents the opportunity to see the SFR area for themselves and better understand how it functioned.
Importantly, some participants also spoke to other parents to learn more about the area, the transfer, and their experience in the SFR. For example, one father described how he was informed about the SFR area by another father on the unit. This was viewed as helpful as it allowed them to learn about the SFRs from a parent's perspective prior to their own transition. Nonetheless, this sharing of information among parents was seen as a supplement and staff were still viewed by most parents as their preferred source of information.
Perception of the Advantages and Disadvantages of the SFR Space
The parents' impression of the advantages and disadvantages of the new space was also a factor that affected their transition. Importantly, parents' perceptions of the effect of the change on their infant played a key role in shaping their transition. As one father stated, "The fact that we are more comfortable improves the experience but our priority was ... our baby's quality of life." Many parents mentioned multiple perceived benefits for their infant, including reduced risk of infection and a less stimulating environment. Some parents also felt that the benefits for themselves and their families also facilitated the transition, including having their own equipment and increased privacy and intimacy with their partner and child. As one father described, "To me it feels like a hotel room. It's like our private space."
However, other parents described what they perceived to be possible disadvantages for the care of their infants. For example, some parents worried about their infant being alone in the SFR and that staff could not respond to the infant as well in the SFRs compared with the pod where their infant was always visible to staff. This concern about the infant's well-being influenced how they viewed the upcoming transition. Similarly, aspects of the SFRs that some parents perceived as negative, such as lower staff ratios and concerns about the different type of monitors, made it more difficult to parents to adapt. For example, 1 couple perceived the transfer to an SFR as negative as they found that the decreased staff ratio made asking questions of staff more difficult.
Parents' Own Well-Being and Quality of Support From Staff
As parents underwent this transition, they perceived that as more difficult when they themselves were not "ready" or were not yet physically or mentally able to care for their infant independently. For example, one mother described that her transfer to the SFR was more difficult because she was still recovering from a cesarean delivery and could not take on the care tasks that she felt were expected in the SFR. Similarly, parents' ability to cope with changes in the NICU in general positively impacted their transition. For instance, some parents commented on their ability to adapt or "go with the flow" and found that this benefited them as they underwent this transition. As one mother described, "But for me ... when it happens, it happens .... I think through the whole process, I have realized that so many things change so I've just come to accept it." As such, the parents' ability to cope with the change was a factor that influenced their transition.
Parents' ability to cope and adapt to the transition was enhanced by support from staff, in particular, nurses. Many parents described how nurses had become crucial sources of support for them throughout their NICU stay. Staff members shared their experiences with them, celebrating their victories and guiding them through challenges. As one mother stated, "Even if we're more independent now in the [SFR], we know that everybody's there for us." Related to this, after the transfer to the SFR having access to the same nurses and other staff members that they had come to trust and be comfortable with contributed to feeling supported. For example, one mother described how a nurse who had cared for her infant early in her hospitalization was the first to tell her about the SFR area and came to check on her and that helped her adjust to the transition.
Parent's Previous NICU and Parenting Experience
Parents' previous experiences in the NICU during the hospitalization shaped their ability to adapt after the transfer. In particular, participating in infant care in the pods, where nurses were more available and visible, was valuable and helped them feel more at ease with the transition. For example, parents who were accustomed to doing much of their infant's care independently felt prepared for the transition. As one mother stated, "it was a gradual change from the start to the end ... by the time we got here we were used to doing [care tasks] on our own."
Similarly, parents with older children considered that having had previous experience with infants helped them adapt to the transition as they already knew how to care for an infant independently. For example, one mother who had a child at home stated how it came back quickly for her how to do care tasks such as bathe or feed an infant and so her adjustment went smoothly. Likewise, a father described how having had a healthy term infant previously made him comfortable evaluating his infant's progress and making caregiving decisions stating, "Having seen normalcy helped a great deal because ... it allows us to better assess the child's progression."
Having previously had a child in the NICU was also viewed as positively impacting the transition. As one mother noted, "The first time, with my daughter, it was difficult .... Because it was my first baby, I didn't know what a premature baby was ... but with him ... it does not stress me out much." As such, even though no parents had undergone this specific transfer before, having had other experiences in the NICU or with infant care helped them feel less stressed and prepared to deal with transitions within the NICU context.
DISCUSSION
This study is the first to our knowledge to specifically examine factors that may influence parents' perceptions of the transition from a 6-bed pod to an SFR in a mixed-design unit. This study found that how staff described or framed the transition, the timing and comprehensiveness of the information staff provided about this event, and the parents' own perceptions of the advantages and disadvantages of the SFR impacted their transition. In addition, parents' own well-being and the quality of support from staff, as well as parents' previous NICU and parenting experience also played a role.
Studies in the NICU context have found that the quality of communication with staff is one of the most significant indicators of care quality as perceived by parents.13 Studies have demonstrated that in addition to information conveyed, other factors, including whether staff who provide the desired information already have a relationship with parents and even staff's tone of voice, impact how information is received.13 Good communication has been linked in the literature to lower stress, increased presence on the unit, and better well-being for parents.13 In our study, parents felt that adequate information from staff about the SFR impacted their transition positively but not all parents received the information they desired. Thus, lack of consistency among staff in providing this information meant that the informational needs of parents were not always met. This points to the need for more training of staff regarding the importance of providing parents with detailed information about the SFRs prior to, during, and after this transition, as well as the need for tools that can assist with meeting parents' informational needs such as an information brochure.
This current study adds to the body of research on staff-parent communication by highlighting the importance of how staff described the transition to the SFR. This finding has been noted in few studies, such as a 2012 study, which found that nurses describing the benefits of moving from a NICU environment to a special care nursery in a different hospital were viewed as facilitating to their transition.14 Our study extends this finding by highlighting what aspects of this specific transition were viewed as beneficial. For example, despite the decreased nurse-to-infant ratio in the SFR area, introducing the transition as an opportunity to assume a greater role in both their infant's care and decision making prior to discharge helped them adapt. Numerous NICU studies have found that parents want to be more involved in the care of their infant.15,16 Highlighting this benefit, among the many others mentioned, could help parents prepare for and adjust to the transition.
Importantly, parents' own perceptions of advantages and disadvantages of the SFR itself also impacted their transition. In particular, some parents were concerned about their infant's safety and comfort when alone in the SFR and this led them to perceive the transition negatively. In studies of staff perceptions of SFRs, infant safety is also mentioned as a concern of staff though, importantly, studies have associated SFRs with better outcomes for infants including lower incidences of apneic events and sepsis.17-19 Recognizing this worry may exist when parents transition to SFRs, staff should explain the external monitoring system and benefits for infants in depth to help reassure parents.
The current study found that support from nurses was important to ease the transition. Many studies of NICU transitions have shown that parents need increased support during transitions both from hospital staff and other sources of support in their support network.2,20 This study expanded on this by describing specifically how parent's own ability to adapt could be improved through support from staff.
Interestingly, the participants in this study identified only the NICU staff as their sources of support during the transition to the SFR and not family and friends. This could be due to participant preference or the time at which this study was conducted. Importantly, our study was conducted during the COVID-19 pandemic when parents were often isolated from their families outside of the hospital. In addition, while this NICU had no restrictions on parental presence during the study period, no other family members or friends were allowed entry and there were limitations on the number of parents permitted in common spaces, which decreased parent-to-parent interactions. Within this study, the staff were the main source of support for the transition perhaps because other sources of support were less available due to the restrictions of the COVID-19 pandemic. Future studies could investigate what sources of support parents deem most beneficial during transition as well as whether other sources of support such as peer support groups could be beneficial.
Parents' own past experiences impacted their ability to transition. In particular, participating in the care of their infant prior to the transition to the SFR was viewed as beneficial. This finding is consistent with studies of NICU discharge, which report that being more involved in care prior to discharge helps parents feel better prepared to assume care of their infant at home.21,22
Parents who had older children, whether they were hospitalized in the NICU or not, considered that their previous childcare experience facilitated their transition to the SFR. Although the impact of having a previous NICU admission has not been explored to our knowledge in NICU transition literature, some studies have examined how parity impacts readiness for discharge and discharge-teaching needs. For example, a study by Mazur et al23 found that parents with other children at home were more prepared to care for their infant independently but may have less time to spend at the hospital. The study also reported how fathers, in particular, may be less present in the NICU if they have other children at home due to caregiving needs of those children.23 Although both mothers and fathers in this study found having other children to be facilitating, these results point to the need for tailored information regarding this transition.
Implications for Practice
This study's findings suggest that staff can have a significant impact on parent perceptions of the transition of their infant from a pod to an SFR. We found that presenting or explaining the transition to parents by focusing on the advantages of the SFR for the infant and the parents in part shaped parent perceptions of the transition. For example, underscoring how the forthcoming transition to an SFR reflects their infant's improved health status and growth and describing the transition as an opportunity to further their learning to care for their child independently before the final transition home were both viewed as helpful by parents. In addition to focusing on the advantages of the transition for the infant and the parents, staff should also aim to provide tailored information to the family regarding monitoring, staffing change, and expectations for parents among other aspects of the transfer and ensure that this information reflects the family's individual needs and past experiences. A formalized process should be developed to ensure that information is provided prior to and throughout the transition to all families in a way that suits their individual needs.
Many parents felt that it would have been beneficial to receive advance notice of this transition to allow them to prepare or the opportunity to be involved in the decision of when this transfer would occur. Improvements could also be made by providing detailed explanations of why their infant is ready for transition at this time. Staff should also be cognizant of how important their support is for parents undergoing this transition. Linked to this, many parents appreciated how the same staff were present in both areas. Although this not be possible in all centers, this finding speaks to the value of having nurses trained in multiple areas, which can facilitate continuity of care as well as enhanced support for parents.
Implications for Future Research
Although similarities were found between this study and others of different NICU transitions, there is a need for more research into this specific transition to validate and expand on the results of this study. It would be useful to gather data outside of the COVID context. Our study was also limited by a lack of parents of twins in our study, so a similar study that included parents of twins who may face additional unique challenges would be valuable.
Intraunit transfers have specific features that can impact families' experience of this type of transition and as such, future studies should investigate parent perceptions of factors affecting transitions within the same unit in different contexts. Studies could also investigate staff perceptions of intraunit transitions as there has been little research into this.7 Finally, studies should also investigate additional sources of support for parents and how these can impact intraunit transitions.
CONCLUSION
This study identified multiple factors that can impact parent perceptions of the transition from a 6-bed pod to SFR in a mixed-room design NICU including how staff frame or explain the transition, parents' own perceptions of the benefits and disadvantages, their experiences of support and personal coping, and parents' previous NICU and parenting experiences. This study highlights the need for a formalized process to guide healthcare staff in their provision of support and information to NICU families undergoing transitions as well as the need for family-centered model of care that is flexible and tailored to the needs of specific families.
References