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  • It’s time to look beyond perceived barriers to Family Integrated Care in the NICU and create a culture for change


    Katie Cullum
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    Summary

    Family Integrated Care (FICare) is an approach to neonatal care which aims to involve parents as equal partners in the care of their babies while in the Neonatal Intensive Care Unit (NICU). FICare aims to minimise separation, support parent-child bonding and promote parental decision-making.

    In this blog, Katie Cullum, Lead Nurse for Innovation and Quality Improvement at East of England Neonatal Operational Delivery Network, talks about the proven benefits of Family Integrated Care and why all NICUs should be implementing the model to improve outcomes.

    Content

    It’s amazing how far we’ve come with medical advancements in neonatal intensive care (NICU) and special care settings over the past decade. Unfortunately, involving families in the care of their infants in NICU does not seem to have progressed at the same pace, despite evidence showing how important this is for the health and wellbeing of premature babies and their families.

    Changes have started to evolve more rapidly nationally since the Neonatal Critical Care Review and through the integration of family care co-ordinators, but it’s still vital that we keep discussing this model of care and its benefits to maintain the momentum for change.

    Why is family involvement difficult in the NICU?

    It is easy to see why family involvement is difficult in NICU just by walking up to a unit and stepping through the front doors.  

    Families are often greeted by a locked door they must enter before being able to see their infants (for security reasons). Once they get let into the unit, they will find their infant behind the closed doors of an incubator or in a cot connected to multiple wires and machines.

    Families must ask staff for help to hold or touch their baby as everything is new in this environment – it is quite frankly scary to people who have not been exposed to it. The environment is often sterile and uninviting with foreign noises and machines. Limited staff availability due to the routines involved in caring for NICU babies means that parents are restricted in the amount of time they can hold their infant.

    Parents get told go home and rest as the NICU environment often does not have facilities for them to stay. Neonatal units therefore disrupt every biological instinct a new parent has to be close their baby, and unfortunately over time it has been culturally accepted that this is ‘normal care’ within a NICU environment. 

    A solution – Family Integrated Care

    In its 'Family Integrated Care Framework', the British Association of Perinatal Medicine defines Family Integrated Care as: 

    “a model of neonatal care which promotes a culture of partnership between families and staff; enabling and empowering parents to become confident, knowledgeable and independent primary caregivers. Neonatal units with a strong FICare philosophy nurture families into this role by listening to them, building on their strengths, and encouraging their participation in experiences and decision-making to enhance control and independence. The FICare model ensures that they can be a family as soon as possible; creating space for necessary medical care whilst facilitating the nurturing bond and love that only they can provide for their baby.”[1]

    There are five principles of FICare:

    1. Partnership: Families are orientated to the neonatal unit and provided with information and resources around the integrated care. They are supported to be primary caregivers throughout.
    2. Wellbeing: Support is provided to allow families to thrive and adopt the FICARE model. Peer supporters, psychologists and wellness classes are given examples of wellness support in the BAPM FICARE model.
    3. Empowerment: parent education classes and peer support allow parents to lead in providing care for their infants. 
    4. Culture: Regular staff education to embed knowledge of the evidence behind this model of care facilitates a culture shift.
    5. Environment: The physical environment is designed to facilitate all the above principles being embedded into the unit within FICARE model. For example, accommodation and facilities must be provided if parents are to be allowed 24-hour access to see their baby. This means all cot spaces having reclining chairs, parents having access to accommodation, kitchen facilities being available so parents do not have to leave the unit for food, onsite childcare and play therapists for siblings and the offer of financial support for travel, food and parking.

    The proven benefits of Family Integrated Care

    The biological instinct for parents to be close to their baby is embedded in our nature, to promote the health and wellbeing of both baby and parent. This is clearly demonstrated by research that compares standard NICU care with Family Integrated Care models, as well as studies looking at the benefits of increased skin-to-skin, kangaroo care exposure and parent contact. FICare promotes higher quality care by facilitating actions set out in the Neonatal Critical Care Review, Ockenden Report and National Neonatal Audit Programme. It also helps to integrate both the BLISS baby charter and UNICEF Baby Friendly Initiative standards.

    Here are some of the benefits of FICare that have been demonstrated in research studies:

    Benefits for the infant

    Infants who have received FICare have been seen to have:

    • reduced rates of infection[2], necrotising enterocolitis[3] and retinopathy of prematurity[4]
    • a shortened time to full suck feeding[5]
    • a reduction in medical intervention needed
    • a reduced length of supplemental oxygen[1]
    • grown more quickly
    • higher breastfeeding rates.[3][6][7]

    Research also shows that infants given increased exposure to skin-to-skin contact have a more stable blood pressure, heart rate, respiratory rate[8], temperature[9] and blood sugar levels.[10]

    Longer term health benefits have also been reported where FICare is compared with conventional neonatal care. Children who had received FICare were described as having improved social skills and fewer emotional and behavioural difficulties.[11] One study also reported higher scores on the mental development index and psychomotor development index at 18 months.[12]

    Benefits for the family

    For families, FICare has been shown to:

    • reduce stress
    • improve mental health
    • increase family bonding
    • lead to better general health.[11]

    Parental confidence in the NICU was found to be higher where FICare was used, and this is likely to be because of the trust and collaboration built with healthcare professionals. When parents become embedded in caring for their baby, the transition to home was also found to be less traumatic.[11]

    Benefits for staff
    • Research has shown that FIcare can alleviate workforce challenges as it promotes increased parental involvement in caregiving, allowing staff more time to undertake other tasks.
    • Increased collaboration and better communication with families developed through FICare increase job satisfaction and reduce stress for NICU staff.[13]
    Benefits for the service
    • NICUs that use FICare have experienced a reduction in length of stay and seen better patient flow, which in turn leads to increased capacity and reduced costs.[2][5]
    • FICare also enables some parts of the infant’s care to be redistributed into the community and decreases the rate of readmission.[2]
    • Improved communication, trust and collaboration and a reduction in the number of incident forms has also been demonstrated with FICare.[14]
    Wider health and societal benefits

    All the positive outcomes listed above create even wider benefits for infants, families and society as a whole. For example, we know that women who have breastfed have a reduced risk of many cancers, so facilitating breastfeeding in NICU is very important.

    Moving forward with Family Integrated Care

    We need to look beyond perceived barriers to FICare, as the benefits for everyone involved are so great. I am hopeful that bigger changes are coming and the role out of FICare will increase with pace over the next decade through the introduction of the BAPM national Family Integrated Care Framework in 2021 and the introduction of a team of national Family Care Coordinators following the Neonatal Critical Care Review in 2019. 

    However, more research, sharing of quality improvement initiatives and discussion of these will encourage shifts in practice that support FICARE. One great example of how this can be achieved is Delivery Room Cuddles, which has been widely publicised and adopted.[15] It has shown that cuddles when the baby is delivered can happen safely, and that families benefit hugely from having this time with their baby.

    References

    Family Integrated Care Framework, British Association of Perinatal Medicine. 17 November 2021
    2 O'Brien, K. Family Integrated Care reduces NICU length of stay and improves medical outcomes across China. The Journal of Pediatrics. 2021:232:307-310
    3 Lv, B, Gao, X, Sun, J et al. Family-Centered Care Improves Clinical Outcomes of Very-Low-Birth-Weight Infants: A Quasi-Experimental Study. Frontiers in Pediatrics. 2019:7
    4   O’Brien, K, Bracht, M, Macdonell, K et al. A pilot cohort analytic study of Family Integrated Care in a Canadian neonatal intensive care unit. BMC Pregnancy and Childbirth. 2013:13(Suppl 1):12
    5 Banerjee J, Aloysius A, Mitchell K et al. Improving infant outcomes through implementation of a family integrated care bundle including a parent supporting mobile application. Arch Dis Child Fetal Neonatal Ed. 2019
    6 O'Brien K, Robson K, Bracht M et al. FICare study group and FICare parent advisory board. Effectiveness of family integrated care in neonatal intensive care units on infant and parent outcomes: a multicentre, multinational, cluster-randomised controlled trial. Lancet Child Adolesc Health. 2018:2(4):245–254
    7 He S, Xiong Y, Zhu L et al. Impact of family integrated care on infants’ clinical outcomes in two children’s hospitals in China: a pre-post intervention study. Ital J Pediatr. 2018:44(1):65
    8 Mitchell, A, Yates, C, Williams, K et al. Effects of daily kangaroo care on cardiorespiratory parameters in preterm infants. Journal of Neonatal-Perinatal Medicine. 2013:6(3):243-249
    9 Ludington-Hoe, S, Nguyen, N, Swinth, J et al. Kangaroo Care Compared to Incubators in Maintaining Body Warmth in Preterm Infants. Biological Research For Nursing, 2000:2(1):60-73
    10 Chiruvolu, A, Miklis, K, Stanzo, K et al. Effects of Skin-to-Skin Care on Late Preterm and Term Infants At-Risk for Neonatal Hypoglycemia. Pediatric Quality & Safety. 2018:2(4):30
    11 Waddington, C, Veenendaal, N, O’Brien, K et al. Family integrated care: Supporting parents as primary caregivers in the neonatal intensive care unit. Pediatric Investigation. 2021:5(2):148-154
    12 Li Y, Gao XY, Xiang XY et al. Effect of family integrate care on the development of preterm infants at 18 months of age. Zhonghua Er Ke Za Zhi. 2016:54(12):902–907
    13 Broom, M, Parsons, G, Carlisle, H et al. Exploring Parental and Staff Perceptions of the Family-Integrated Care Model. Advances in Neonatal Care. 2017:17(6):E12-E19
    14 Yang, M, Du, J, Yang, Q et al. Influence of Family Integrated Care on the Intestinal Microbiome of Preterm Infants With Necrotizing Enterocolitis and Enterostomy: A Preliminary Study. Frontiers in Pediatrics. 2021:9
    15 Clarke, P, Allen, A, Atuona S et al. Delivery room cuddles for extremely preterm babies and parents: concept, practice, safety, parental feedback. Acta Paediatr. 2021:110(5):1439-1449

    About the Author

    Katie Cullum is a children's nurse by background. She worked for many years as an Advanced Neonatal Nurse Practitioner before taking on the role of nurse education programme lead for the East of England Operational Delivery Network (ODN). She was the programme lead for the Neonatal Transitional Care Programme, a national programme of study which was shortlisted for a Nursing Times award in 2021. She has since taken on the position of Lead Nurse for Innovation and Quality Improvement at the East of England Neonatal ODN.

    All views expressed in this blog are Katie's own.

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