Around the world, neonatal intensive care units (NICUs) had to adjust many of their routine practices due to coronavirus disease-2019 (COVID-19) while trying to continue to provide excellent care for newborns and their families. Prior to COVID-19, most NICUs used family-centered care as the framework to engage parents in infant caregiving.1 However, due to the need for urgent implementation of COVID-19 crisis management procedures in early 2020, family-centered policies regarding parental presence in the NICU were quickly modified to restrict parents' presence at the bedside. New policies varied from unit to unit and even changed over time, as we learned more about how the virus spreads. Yet, as 2020 turned into 2021, many of the restrictive parent presence policies have been slow to return to prepandemic standards despite an increased understanding of the virus spread, implementing safety protocols for healthcare workers that could have been adapted for parents, and knowing that parents as caregivers are essential to excellent neonatal care. Infants develop best when they are emotionally and physically attached to their parents. Parent presence and participation in care results in improved outcomes for both newborns and parents. Randomized controlled trials that employed family-centered care interventions resulted in increased newborn weight gain, decreased readmissions, and decreased parental anxiety, depression, and stress.2
During the pandemic, some of the reported restricted parental presence policies included: allowing only one parent to visit at a time; decreased mothers' presence to 2 hours per day; and, limiting fathers' presence to 1 hour per week.3 In one cross sectional survey of 277 NICUs, parental presence 24 hours per day 7 days per week decreased from 83% to 53%.4 These strict restrictions have led to parents requesting to be allowed back into NICUs.3,5 For example, after an informal survey of parents revealed concerns about family restrictions during the pandemic, the Vermont Oxford Family Faculty spoke out and stated that parents should be allowed back in the NICU to participate in care.5 Jennifer Canvasser, a former NICU parent who lost her son to necrotizing enterocolitis in 2012 and founder and director of The NEC Society, wrote about the importance of parental presence in the NICU to ensure shared decision-making at the bedside.3 Both the Vermont Oxford Family Faculty and Canvasser asked that partnerships with parents to be recognized during these complicated times. As NICUs grappled with these decisions, NICUs could have looked to use guidance from experts, such as the Institute for Patient and Family-Centered Care (IPFCC), to help make sure that parents were included in decisions at both the bedside and at the hospital level through the use of the IPFCC's pandemic planning resources.6,7
As in most pandemic work environments, extended use of technology is already in place in the NICU and new online platforms played a major role in connecting with families due to limited parental presence.8 Technology may have been an appropriate early solution to parent engagement as units learned about the pandemic, yet it was never meant to replace in-person visits.9 Seeing their newborn during physical separation may have been helpful to parents; however, it was insufficient.5 Parental presence as an active caregiver fosters infants' security and parent–infant attachment.10
As neonatal nurses we must continue to advocate for parents to be fully involved in their newborn's care and ensure that parents feel supported throughout the NICU stay. That is why NANN has joined with the National Perinatal Association and the Association of Women's Health Obstetric and Neonatal Nurses Association in the Consensus Statement on Family Presence in Neonatal Intensive Care Units.11 During the pandemic, the parent/caregiver role has not been seen as “essential” and parental presence in the NICU was not as hardwired into our culture as many would have liked to believe. We must now fully embrace parents as “essential caregivers” to the care of their infants in the NICU and avoid slipping back into the habit of labeling parents as visitors. Parents need supported in their need to be able to routinely participate in their newborn's NICU care. We need to advocate for the holistic care of newborns, parents, and families to support our family-centered decisions at the unit, local, and national levels. Parents are essential; they must become the “constant” and not the “visitor.” It is now time for all neonatal clinicians to partner with parents so that infants and families can fully benefit from family-centered care.
—Jodi Herron Behr, PhD, APRN, RNC-NIC, ACCNS-P
Assistant Professor, Texas Woman's University
—Debra Brandon, PhD, RN, CCNS, FAAN
Co-Editor; Advances in Neonatal Care
—Jacqueline M. McGrath, PhD, RN, FNAP, FAAN
Co-Editor; Advances in Neonatal Care
1. Franck LS, O'Brien K. The evolution of family-centered care: from supporting parent-delivered interventions to a model of family integrated care. Birth Defects Res. 2019;111(15):1044–1059. doi:10.1002/bdr2.1521.
2. Ding X, Zhu L, Wang L, Wang TT, Latour JM. Effects of family-centered care interventions on preterm infants and parents in neonatal intensive care units: a systematic review and meta-analysis of randomized controlled trials. Aust Crit Care. 2019;32(1):63–75. doi:10.106/j.aucc.2018.10.007.
3. Canvasser J, Payton K., Rogers E. In the NICU, both parents are essential and need to be at their child's bedside. https://www.statnews.com/2020/07/13/nicu-both-parents-essential-childs-bedside/
. Published July 13, 2020. Accessed December 21, 2020.
4. Mahoney AD, White RD, Velasquez A, et al. Impact of restrictions on parental presence in neonatal intensive care units related to coronavirus disease 2019. J Perinatol. 2020;40(suppl 1):36–46. doi:10.1038/s41372-020-0753-7.
5. Bainter J, Fry M, Miller B, et al. Family presence in the NICU: constraints and opportunities in the COVID-19 era. Pediatr Nurs. 2020;46(5):256–259.
6. Institute for Patient and Family-Centered Care. Pandemic planning and patient-and-family-centered care. https://www.ipfcc.org/resources/downloads.html
. Published October 2010. Accessed December 21, 2020.
7. Institute for Patient and Family-Centered Care. COVID-19 and patient-and-family-centered care frequently asked questions. https://www.ipfcc.org/bestpractices/covid-19/index.html
. Published April, 2020. Accessed January 11, 2021.
8. Guttmann K, Patterson C, Haines T. Parent stress in relation to use of bedside telehealth, an initiative to improve family-centeredness of care in the neonatal intensive care unit. J Patient Exp. 2020;7(6):1378–1383. doi:10.1177/2374373520950927.
9. Epstein EG, Aregchiga J, Dancy M, et al. Integrative review of technology to support communication with parents of infants in the NICU. J Obstet Gynecol Neonatal Nurs. 2017;46(3):357–366. doi:10.1016/j.jogn.2016.11.019.
10. Gardner SL, Voos K. Families in crisis: theoretical and practical considerations. In: Gardner SL, Carter BS, Enzman-Hines MI, Hernandez JA, eds. Merenstein & Gardner's Handbook of Neonatal Intensive Care: An Interprofessional Approach. 9th ed.St Louis, MO: Elsevier; 2021:1039–1095.
11. Association of Women's Health Obstetric and Neonatal Nurses, National Association of Neonatal Nurses, National Perinatal Association. Essential care in the NICU during the COVID-19 pandemic. National Association of Neonatal Nurses. http://nann.org/about/position-statements
. Published January 2021. Accessed January 13, 2021.