The phenomenon of parent presence is a topic of constant discussion among healthcare professionals in the neonatal intensive care unit (NICU). With the advent of family-centered care giving, parent presence has become increasingly supported yet, for the most part frequency and duration of parent presence in the NICU does not appear to be increasing. There are many studies in the literature about parent presence that can be helpful to our discussion of this important topic. In an exemplary study by Brown et al1 with a sample of 65 very low birth weight infants, mothers visited most often. Typically they visited twice a week; with fathers visiting most in the first week of life and less often thereafter. Not surprising, it was also noted that unmarried, younger mothers with little or no insurance or private transportation visited even less often. Although this is not a new study, it is exemplary because the findings are mostly true even today. Moreover, Franck et al2 found that mothers who were more involved in feeding and care giving activities with their infants were more likely to visit and those visits were of longer duration than mothers who did not actively participate in care. In this study, distance from the NICU was also found to be a major contributing factor to the amount of parent presence; overall parents who lived farther from the NICU visited less often.2

There are many reasons parents do not visit. Some are not as easily addressed by healthcare professionals such as transportation and childcare for siblings. However, there are several different strategies that healthcare professionals can use to increase parent participation and thus, support family visiting. For example, most NICUs in the United States have 24-hour visiting for parents as a unit policy; yet, in almost every one of these same NICUs have hidden somewhere in tiny print or unwritten policies; times when parents are asked to leave the unit or are unwelcome to visit. Examples include: asking parents to leave at staff shift change; during rounds; during a resuscitation or critical event; or when a specialist visits the child, procedures are performed, or both. When a 24-hour open visiting policy exists, asking parents to leave during these events sends conflicting messages to families about their role in the NICU. For parents, when it seems like the rules are always changing, and different staff enforce or allow different privileges for different parents at different times; it might not seem like the environment of the NICU is truly welcoming to the families. Inconsistent messages lead parents to begin not to trust the NICU environment and they are more likely to feel less and less welcome. Posting or sharing consistently with the families the true visiting times as well as providing sound rationale for why parents can or cannot visit during these times or will be asked to leave is important in sending the message that parent presence is important.3,4 In addition, what we say to families about their presence and participation is also important.5

The following scenario is provided to illustrate how easily this can occur and how even when none of the healthcare professionals are truly at fault, differences in communication can lead parents to believe many different things about whether their presence is truly welcomed.

A 27-week gestation infant was progressing well in the NICU with noninvasive ventilation on the third day of life. His mother had been discharged but was staying nearby and visiting daily. She had provided skin-to-skin holding the previous day and it had been well tolerated by the infant. Both she and her husband had participated and it had been a positive experience and the parents truly felt welcome on the unit. The mother arrived on the unit in the afternoon, and she was immediately told that the infant had had a very stressful morning (blood draw, and difficult peripheral IV start requiring some increase oxygenation needs). The nurse went on to say that it would not be a good afternoon for skin-to-skin holding. The mother listened carefully and not wanting to do anything that would be hurtful to her infant did not hold her infant. She did remain at the bedside, stroking her infant and talking gently to him for the remainder of the afternoon. After shift change, a new nurse who the mother had not previously met, almost immediately offered to help the mother with skin-to-skin holding. The mother was very confused, of course she wanted to hold her infant, yet, the previous nurse who she knew and trusted had said it would be not good for the infant. The new nurse is just that, new to the mother and to the infant. The mother seemed reluctant and the new nurse took that behavior to mean that the mother did not want to hold her infant, and began to tell the mother all the reasons skin-to-skin was good for the infant. The mother did not know what to say. How does she explain to the nurse that the dilemma is about who to trust? The mother doesn't want to say anything "bad" about the nursing staff; she needs to be able to feel they "like" her and her infant. In the vulnerability of the situation, the mother is truly ambivalent about what to do. She delays the holding of her infant by saying she needs to go get something to eat first. Leaves the unit and does not come back for a few hours.

This scenario exemplifies how trust, power, and vulnerability are present and consistently influence how the helping relationship develops between the nurse in the NICU and parents. Carter6 characterizes helping as the moral center of the nurse-patient relationship. As the nurse meets the parent's expectations for help and caring, the nurse is perceived as trustworthy and supportive by the parent. In turn this trust decreases the parent's sense of powerlessness and vulnerability. Trust for parents in the NICU is the confident expectation that others can be relied upon to act with good will and to secure what is best for their infant who needs help. Trust is gained through consistent communication that says both parties (parents and healthcare professionals) are valuable; both have a place in this child's life and both are needed while the infant is in the NICU. Ultimately, it must be acknowledged that the parent is more valuable to the infant than the nurse and the relationship between the parent and infant must be fostered and supported even at the cost of the relationship with the nurse.

Meiers et al7 developed and tested the Family Nurse Caring Belief Scale (FNCBS) to measure nurse attitudes regarding provision of family-sensitive care to families in crisis in both the NICU and in the pediatric intensive care unit (PICU). The FNCBS is a 27-item scale that asks the nurse to agree or disagree with each of the items on a Likert-type scale ranging from 1 to 5. Most nurses can complete the scale in less than 5 minutes. The scale has been found to have good reliability (0.81--NICU; 0.78-PICU) and validity (r = 0.57). Further testing with larger and more diverse populations is needed. Using instruments such as the FNCBS as well as providing education and support for nurses to integrate family care giving into their routine care requires consistent system support. As the previous scenario exemplifies, no one nurse or caregiver can provide this type of care alone; it must be consistently provided by all caregivers for there to be a positive effect.

I personally believe that parents are not visitors. I believe they are our partners in care giving for their infant(s) and as such they are collaborating members of the care giving team in the NICU. Yet even in 2011, and even with the widespread notion of family-centered care giving, all healthcare professionals in the NICU do not universally share my beliefs. This is not a new or novel notion but it is one that pushes each healthcare professional to examine their personal values and beliefs about the needs of our patient population and if they do not believe that the population includes parents then the most desirable long-term outcomes for the infants are not achievable. To that end, neonatal nurses must also perfect their skills for family care giving with the same enthusiasm that they work to advance their skills for caring for high-risk newborns and infants.

-Jacqueline M. McGrath, PhD, RN, FNAP, FAAN

Associate Professor

School of Nursing

Virginia Commonwealth University

Richmond, Virginia

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