There are a lot of qualitative studies that make huge generalizations from the very tiniest of samples; on the other hand, some studies of values and wishes of parents and patients can be valuable, and can be well studied only with qualitative techniques. One example of the latter is a new study from 3 centers in France. (Guillaume S, Michelin N, Amrani E, Benier B, Durrmeyer X, Lescure S, Bony C, Danan C, Baud O, Jarreau P-H et al: Parents’ expectations of staff in the early bonding process with their premature babies in the intensive care setting: A qualitative multicenter study with 60 parents. BMC Pediatrics 2013, 13(1):18.) They interviewed 30 mothers and 30 fathers with very preterm babies in NICU. It is worth a read (freely available on BMC Pediatrics) and I will quote in its entirety the conclusion section of the abstract:
‘At birth and during the first weeks in the NICU, the creation of a bond between mothers and fathers and their premature baby is rooted in their relationship with the caregivers. Nurses’ caring attitude and regular communication adapted to specific needs are perceived by parents as necessary preconditions for parents’ interaction and development of a bond with their baby. These results might allow NICU staff to provide better support to parents and facilitate the emergence of a feeling of parenthood.’
Another study points out the importance of nurses attitudes to what happens in the NICU and to parental experiences. A US study, from an urban center, questioned nurses and mothers about things like whether parents should participate in care of the baby and whether they should be encouraged to be present and to do kangaroo care. (Hendricks-Munoz KD, Li Y, Kim YS, Prendergast CC, Mayers R, Louie M: Maternal and neonatal nurse perceived value of kangaroo mother care and maternal care partnership in the neonatal intensive care unit. American journal of perinatology 2013(EFirst).) I was very surprised by the results. Only 21% of nurses strongly agreed that parents should be encouraged to be present in the NICU, and only 67% of mothers! Knowledge and attitudes towards Kangaroo Care were also poor, and differed greatly between nurses and mothers. The authors identified many barriers to creation of maternal care partnerships that need to be overcome.
My own recent experience concurs that nurses play a surprisingly key role for parents in forming attachment to their NICU infants. As a mother of a micro-preemie, I have spent the last two months in an NICU and overall have had very positive experiences with nurses, who have helped me to find a role as mother in this strange environment and shown me ways to bond with my baby.
However I think the “first visit” of mother and baby (or parents and baby) is a powerfully formative experience that is currently overlooked by those NICUs that do not have a special process in place to ensure this goes at least moderately well.
The other day I was reading a text about premature babies written for parents, and it described the trauma you might experience in being separated so abruptly from your baby at birth: “You might have had a C-Section, and your baby may have even been too fragile to be immediately put to your breast after birth. In some cases, your baby has to be moved very quickly to the NICU to get assessed and stabilized. If that happens, don’t worry, your baby will probably be brought to you for a visit shortly, or you will be taken to the NICU in a wheelchair as soon as you’re ready. In some cases, the mother and the baby are too ill for this to happen right away; then, perhaps a nurse will bring you some photos of your baby so you can see what a treasure you have! However, it’s important to acknowledge that these scenarios are not the birth experiences you envisioned.”
I read this description and thought it sounded pretty great compared to how things rolled out for me. I had a C-Section and my 590 gram baby was whisked to the NICU while I slept after 11 days of HELLP Syndrome which left me very weak. The next day, an orderly took me for an X-ray, and my nurse casually mentioned to me that I could ask the orderly to take me to visit my baby on the way back if I wanted, so I asked the orderly to do so.
[An aside – in my experience, orderlies come in two varieties: those who are the kindliest souls who guide the wheelchair with painstaking care over any bump that could make you uncomfortable, and then you have those that wheel you one-handed over debris and into walls while they’re busy texting and emanating death-rays of hatred for their jobs. I had the latter. She dumped me unceremoniously in the room of my baby and took off.]
I was pretty overwhelmed by the NICU on my first visit. I did not realize that it would be such a “medical space”, full of machines I’d never seen, beeps and alarms, space-age looking incubators, dim lights that made it challenging to see my baby, and no comfortable chairs or spaces that looked like parents were “meant” to occupy. I did not encounter any nurses during that admittedly short first visit. I tried to stand in front of my wheelchair to get high enough to see into the incubator properly, but was too weak to do it for more than about thirty seconds and gave up with a vague impression of a baby-like form in the incubator’s warm depths. I felt numb and wondered if it was even mine. After three or four minutes, I fled, weeping.
Looking back, I think this first experience took me a long time to overcome by having many more positive experiences to replace it with, experiences that made me feel I belonged by my baby – little things like a nurse saying “you’re the mother!”; “let’s lower the incubator so you can see her”; “how are you feeling today, Mom?”. That first visit has stayed with me. As with first impressions, a little goes a long way, and first NICU visits punch above their weight.
Now, looking back, what’s remarkable is that it happened to roll out that way. Most times I’ve visited my baby over the last two months, I’m greeted by a friendly nurse who introduces him/herself and asks if I’m the mother. Some of the nurses also offer me a chair or in some way try to ensure I make myself comfortable. Both of these acts send the message that despite the machines, beeps, flashing lights, and uniforms, I as the mother belong in this space, too. When these things don’t happen, it’s usually because my baby’s nurse is on a break, and the remaining nurse is pretty busy occupying herself with four babies. So realistically, we can expect no “welcoming committee” about 25% of the time due to breaks and the odd less friendly nurse.
25% of the time is too high when we consider the impact of a bad first experience for a brand new parent. I suggest that NICUs adopt a simple standardized process to ensure positive entries for parents into the NICU world. I work as a process consultant myself, so I think the easiest way for an NICU to create and implement an effective process would be to ask a nurse and a parent to come up with something together, as you want something easy that will work in well with a particular NICU’s existing procedures, staffing, practices and resources. But here are a few starter ideas:
– put a sign on the door of the NICU that says “Mom / Dad – is this your first visit? Please tell the receptionist”. The receptionist then calls ahead to your nurse to tell them to roll out the red carpet a bit. If she is on break or exceptionally busy, she can then call for additional support in the room. This policy would be particularly effective if orderlies are also informed about this process in case the sign on the door is missed.
– have volunteers (there are often volunteer greeters) take on the role of guide for first time parents, accompanying them to their baby’s room. Volunteers would need some simple training on how to do this effectively and collaboratively with the baby’s nurse. The downside of this idea is that there are only volunteers available during peak visiting hours, so a back-up plan would be needed for other times.
– deliver a little “welcome note” or card to parents after the birth but before the first visit, saying something like “Congratulations on the birth of your baby. We know that you would like to be closer to your baby right now, but we are taking good care of him / her, and look forward to your first visit to NICU. Please present this card to reception when you arrive so that we know it’s your first time here and we can take good care of you.” The card is both a welcoming mechanism and helps stream parents into either of the above processes.
– have a nurse or orderly from NICU actually visit the mother’s bedside and offer to take her to visit her baby. If she is not well enough, the NICU ambassador can tell her a bit about her baby and prepare her for her first visit. This, of course, would be the best option but also the most resource-intensive.
Do some NICU’s already have entry processes in place for parents’ first visits? I wonder what those are?
For any NICU’s wishing to create an entry process, I’d be happy to volunteer to help any way I can, whether that would be sharing my experiences with nurses / volunteers / orderlies, designing a mini-training session, or working with a small team to identify and implement a process from start to finish.
Happily, in my experience NICU nurses are already so friendly and attentive to parents that I think establishing a successful entry process would require relatively little.
lise [at] sparkorganisations [dot] com