The Close Collaboration with Parents intervention aimed to improve the skills of neonatal staff to collaborate with parents and was found to substantially increase parents’ presence and SSC in nine Finnish hospitals. We emphasized the infant perspective in the analyses by showing the time either parent was present (together or alone) in the neonatal unit. Our results showed the intervention increased parental presence by 37% and SSC by 51%.
Importantly, the intervention increased parental presence at both ends of the variation: the shortest pre-intervention presence in one of the study units was 4.2 hours, which aligns with some previous studies18, 27, 26; the highest presence was 18.7 hours in a unit which had single family rooms. Parent-infant SSC varied between an average of 36 minutes to 182 minutes per day in the baseline measurements of the units. Previous studies show that the duration of SSC varies largely when comparing NICUs internationally, with some units having just less than half an hour of SSC per day while others had over eight hours per day18. It has been shown that providing the possibility for overnight stays in the NICU increases both mothers’ and fathers’ presence and SSC29. The level of the NICU where the infant was born did not affect the closeness between preterm infants and their parents, suggesting that the training program can be utilized in NICUs with different acuity levels.
Earlier studies have traditionally focused on mothers’ presence only. In our study, mothers’ presence increased by 41% and fathers’ presence increased by 22%. The weaker response in the duration of fathers’ presence might reflect traditional values related to their role as a parent, conflicting needs from household work and employment, and lack of support30. If there were older siblings in the family, the duration of fathers’ presence was shorter than in families without siblings. Previous literature has also recognized older siblings as a barrier for parents’ presence in the NICU, especially for fathers27, 31. Importantly, fathers have reported that they expect the staff to invite them to be actively involved, and mixed messages about their involvement from the staff serve as primary barriers30.
Mothers’ SSC increased by 38%, but there was no statistically significant increase in fathers’ SSC. It is interesting to speculate why fathers’ SSC did not increase even if their presence in the unit increased. It might be that SSC has been used to promote breastfeeding, which could explain lack of increase in fathers1. Barriers and enablers for SSC include infant’s size and age and lack of knowledge about SSC32. However, low gestational age was not a barrier in our study, but rather increased the duration of SSC. As reported in other studies one common barrier in SSC has been the staff’s disbelief in the importance of SSC32. The training program also provided staff the skills to better detect the stability and well-being of infants (training program Phase I). When noticing better stability of infants during SSC, the staff may be better motivated to facilitate SSC and overcome the possible barriers. Staff also learned to notice the benefits of SSC for parents (training program Phases II and III), further supporting its implementation. As it is often more challenging to have fathers involved in SSC, fathers’ experiences related to SSC should be better understood to know how the training program could better meet their needs. The training program should emphasize the fact that SSC given by mothers and fathers is equally beneficial for the child33, and both parents report SSC as meaningful for them34, 35.
Our results indicate the importance of a systematic, goal-oriented approach in staff training to integrate parents in infants’ care. Our results suggest that Close Collaboration with Parents intervention promotes parental presence and SSC which has been shown to associate with better child outcomes1, 9, 10, 11, 12, 13, 14. It is likely that traditional hospital practices do not change easily by themselves. The aim of our training program was to actively involve parents and negotiate with them about their presence and participation during newborn care. The intervention had features which enabled its adaptability in different contexts. Most importantly, the staff of the target hospitals decided themselves which practice changes were most relevant to carry out in their hospitals; the intervention aimed to change experiences, attitudes, and values behind these family centered care practices. However, this study was carried out in a high-income country that offers financial compensation for parental leaves for both parents after a delivery. Therefore, the results might not be generalizable to less affluent countries.
We changed care culture, focused on better communication with parents, and integrated parents as primary caregivers in NICUs23. The Close Collaboration with Parents training has been shown to decrease mothers’ depressive symptoms36. There have also been other parenting interventions in NICUs, but they have not measured parents’ presence37, 38, 39, 40, 41. One intervention asking parents to be present for 6 hours a day improved growth in preterm infants and decreased parents’ stress and anxiety37. Parenting interventions have been shown to lead to better child development and increased parent wellbeing42, 36. The mechanisms for these positive outcomes might include psychosocial support, parenting education, developmental support and preparing parents to parenthood43. Our study suggests that parent-infant closeness is a potential mediating mechanism explaining the beneficial effects of parenting interventions. Therefore, it is important to include parent-infant closeness measures in parenting intervention studies.
This study did not have concurrent controls without intervention. There might be a time trend towards better understanding of the value of family centered care and, thereby, increasing in parents’ involvement during the study period. However, we did not find any time trends as parents’ presence before the intervention did not systematically increase over the study period. We wanted to implement the intervention in the whole unit in order to change the care culture of the unit. Therefore, a randomized study design within a unit was not applicable. In future, a cluster randomized study design would provide more solid information. We did not perform power calculations as we did not have preliminary information on effect size, but the significant effect proves sufficient power. The units had comparable architectural layout before and after the intervention measurements; none of them had renovations between the two measurement periods. As all nine hospitals were in Finland, this data did not prove that the training effects are similar in other countries or health care systems. However, the training program was effective in different contexts within Finland. One limitation in our study is a potential selection bias, as those parents who are less present might be less likely to be recruited for the study. However, the proportion of parents participating was similar, and high, in both before and after the intervention, so this bias is likely to have a similar effect in each cohort. In addition, we interpreted the days with empty diaries to be indicative of zero parental presence. We aimed to capture the parent perspective and collected the data from parents. Although we validated the parent diaries against nursing charts, it is possible that there are omissions in parents’ diaries44.