EDITORIAL
Family integrated care: new perspectives for neonatal care
Mariana Bueno1, Ana Claudia Garcia Vieira2, Fabiana Bacchini3
1The Hospital for Sick Children, Toronto, ON, Canada
2Federal University of Rio Grande, Rio Grande, RS, Brazil
3Canadian Premature Babies Foundation, Toronto, ON, Canada
Over the years, the highly technological environment of the Neonatal Intensive Care Units (NICUs) has allowed the survival of increasingly more premature and sick newborn infants. In parallel, physical distancing increased between hospitalized infants and their families, culminating with parents having restricted access to their children, limited to few daily hours of contact and interaction. However, this separation can negatively influence the recovery and development of the newborns and infants who remain hospitalized for extended periods of time. It is currently known that parents play a critical role in promoting positive health outcomes during hospitalization and after hospital discharge of these newborn infants.
Family Integrated Care (FICare) emerges as a care model that promotes a culture of collaboration between families and healthcare team, favoring and facilitating that parents become the primary caregivers of their infants, in addition to promoting self-confidence, knowledge and independence(1).
The FICare strategy was developed in Canada by a group of parents who had already experienced hospitalization of their children in NICUs (also known as veteran parents), physicians, nurses, parent educators, lactation consultants, and social workers, and is based on the paradigm change proposed by the `Humane Neonatal Care´ model developed in Estonia(2). FICare is based on four pillars: (1) the NICU environment, which should enable parental presence for as long as possible; (2) professional training to promote family involvement in care and tools to coach and support the families; (3) bedside education for the parents, in order to share knowledge and foster self-confidence and skills; and (4) providing psychosocial support for families(3).
Integrating parents in the care of their newborn infants' starts at admission when the necessary medical care is offered while bonding with the families is also promoted(1,4).
FICare is different from family-centered care as it expands and strengthens the role of families in the provision of care, and provides education, support and collaboration. In neonatal units that adopt FICare, the families are listened to, their values and skills are identified and strengthened and their participation and decision-making are encouraged, in order to enhance their independence and leading role(1).
In a pilot study at a NICU that compared 31 neonates enrolled on FICare to 62 newborns who received usual care, increased weight gain during hospitalization and higher breastfeeding rates at discharge were observed, whereas the mothers in the FICare group presented lower stress levels(2). More recently, in a multicenter clinical trial, the group of neonates that were offered FICare (n=891) presented more weight gain and a higher daily breastfeeding frequency, in addition to lower maternal anxiety and stress scores when compared to the Control Group (n=895)(5). Finally, ten units were randomized to provide FICare and another ten maintained their usual neonatal care practices in a community-based clinical trial. The results indicated lower hospitalization times among the newborns receiving FICare and, in addition to that, no increase in readmissions or visits to the emergency service was observed in this group(6).
Additionally, the benefits extend to parents as there is greater participation in care during hospitalization, improved bonding, and a reduction in depressive and stress symptoms in parents who experienced FICare, compared to parents of families who received usual care(7).
Integrating families into neonatal care in NICUs requires a profound cultural shift whereby health professionals educate and support parents(6).
In the Brazilian scenario, one of the main challenges is considered to be the change in healthcare teams' behavior towards the autonomy and involvement of parents as a distinct and necessary process, to be recognized and encouraged in order to promote not only the health but also the well-being of newborns and their families. This involves developing educational programs and collaboration with parents, while providing support in a manner that emphasizes partnership and inclusivity, rather than the traditional paternalistic approach that persists in clinical contexts. The physical infrastructure of NICUs should not be viewed as a determining factor for adopting a care strategy that promotes the continuous presence of parents in healthcare institutions, despite the absence or inadequacy of physical space. Finally, management support is considered essential, at the different hierarchical levels, so as to promote and protect the rights of infants and their families. It is fundamental to ensure extended maternity leaves in cases of prolonged hospitalizations, recently approved in the country. However, ensuring paternity leave and implementing effective and comprehensive social, emotional and spiritual support strategies are necessary measures to integrate parents to neonatal care.
Reflecting and reviewing concepts, preconceptions and beliefs about what is best for these families requires time and expert support (e.g., veteran parents and health professionals), either on how to assess the results of studies reflecting the aspects regarding satisfaction with care and its repercussions on health improvement or with the possibility of conducting mentoring/guidance sessions for the health teams that wish to implement FICare in Brazil.
A broad restructuring process is necessary for families to be incorporated to and seen from another care perspective: they are the primary caregivers, capable of meeting their children's basic needs in the hospital environment, as well as of providing continuity of care at their homes.
REFERENCES
1. British Association of Perinatal Medicine. Family integrated care: a framework for practice [Internet]. London: British Association of Perinatal Medicine; 2021 [cited 2023 Feb 10]. Available from: https://www.bapm.org/resources/ficare-framework-for-practice
2. O'Brien K, Bracht M, Macdonell K, McBride T, Robson K, O'Leary L, et al. A pilot cohort analytic study of Family Integrated Care in a Canadian neonatal intensive care unit. BMC Pregnancy Childbirth. 2013;13(Suppl 1):S12. https://doi.org/10.1186/1471-2393-13-S1-S12
3. Lorié ES, Wreesmann WW, van Veenendaal NR, van Kempen AAMW, Labrie NHM. Parents' needs and perceived gaps in communication with healthcare professionals in the neonatal (intensive) care unit: a qualitative interview study. Patient Educ Couns. 2021;104(7):1518-1525. https://doi.org/10.1016/j.pec.2020.12.007
4. Zanoni P, Scime NV, Benzies K, McNeil DA, Mrklas K, Alberta FICare in Level II NICU Study Team. Facilitators and barriers to implementation of Alberta family integrated care (FICare) in level II neonatal intensive care units: a qualitative process evaluation substudy of a multicentre cluster-randomised controlled trial using the consolidated framework for implementation research. BMJ Open. 2021;11(10):e054938. https://doi.org/10.1136/bmjopen-2021-054938
5. O'Brien K, Robson K, Bracht M, Cruz M, Lui K, Alvaro R, et al. 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. https://doi.org/10.1016/S2352-4642(18)30039-7
6. Benzies KM, Aziz K, Shah V, Faris P, Isaranuwatchai W, Scotland J, et al. Effectiveness of Alberta Family Integrated Care on infant length of stay in level II neonatal intensive care units: a cluster randomized controlled trial. BMC Pediatr. 2020;20(1):535. http://dx.doi.org/10.1186/s12887-020-02438-6.
7. van Veenendaal NR, van der Schoor SRD, Broekman BFP, Groof F, van Laerhoven H, van den Heuvel MEN, et al. Association of a Family Integrated Care Model with paternal mental health outcomes during neonatal hospitalization. JAMA Netw Open. 2022;5(1):e2144720. https://doi.org/10.1001/jamanetworkopen.2021.44720.