Our aim in this study was to develop and pilot test FIC in a Canadian NICU. It is a model of care that addresses the need to facilitate a care partnership with parents of NICU infants and promote maternal development in the NICU [20, 21]. Unlike other cultural settings where FIC has been adopted, our discussions with families and NICU staff indicated that to make such a model feasible in Canada, in addition to physical and environmental supports, we needed to add other dimensions to our program, specifically parent education, parent-to-parent support, and nursing education. We also had to adapt the requirements of the program to enable families to participate in their infant’s care despite not being able to commit to living at the hospital 24 hours a day, which is a requirement in other care-by-parent models [2, 8]. However, this study demonstrates that with these modifications, the introduction of FIC to a Canadian NICU is feasible. In addition, our study suggests that FIC appears to improve the short-term outcomes for both infants and their parents in the NICU.
Previous reports in the literature on the topic of family-centred care interventions in the NICU appear to be grouped into 2 major fields, those focusing on the provision of parent education and those more focused on the care-by-parent model, whereas our FIC program combined the two. The literature on the benefits of providing educational interventions alone to parents of preterm infants is mixed. In a cluster randomised trial across 6 neonatal centres in the UK, of a parenting educational intervention to enhance parental care of the infant, Glazebrook et al,. were unable to demonstrate any significant changes in parent or infant outcomes . A recent study of a skill-based program called “cues” was also unable to demonstrate any additional benefit over non-specific education . However, in a randomised controlled trial, Melnyk et al., demonstrated that the COPE program, which focuses on providing parents with a very structured educational-behavioural program, improves parent coping and mental health outcomes during and after hospitalization, as well as shortening infants’ length of stay . Whether the use of a specific educational program alone without the additional expectations of parent involvement in their infant’s care will translate into similar benefits in other outcomes, as observed in our study, remains to be seen. What we have heard from our parents is that although the education sessions were useful, being able to participate as part of the care team and having clear expectations of their role was even more important.
The reports of care-by-parent models in the literature, such as those by Levin et al.,  and Ortenstrand et al., , have not specifically described a program of parent education but do require parents to be present in the hospital 24 hours a day. A randomised controlled trial of the “Stockholm” model by Ortenstrand et al., reported a shorter length of stay in hospital and a decrease in bronchopulmonary dysplasia in infants cared for by their parents, suggesting that parental involvement can decrease some of the short and long-term morbidities of preterm birth. Our FIC program supports parents’ ability to spend more time at the bedside by providing clear expectations of the parent, particularly an expectation of a time commitment, as well as rest space and psychosocial supports, but we did not expect parents to provide 24-hour care. The decision to not require 24-hour care was based on many different factors; the physical limitations of our unit, the social context of our families living in a city often with limited extended family support (particularly as many of these families had other children); and the perceived cultural unacceptability of making such a demand of families. However, research staff observed that most of the parents gradually increased the amount of time they spent in hospital beyond the required 8 hours, particularly as their infants’ progress with oral feeding required their extended presence, although this was not formally assessed.
As this was a pilot study and the sample size was small, statistical power was limited; however, it is important to note the interaction of weight gain and time, indicating a greater improvement in the FIC group over time. A larger trial will clarify whether this is a true benefit of the FIC program. However, the significant increase in breast feeding rates is remarkable given how difficult it can be to establish breast feeding in preterm infants . The provision of breast milk feeds to preterm infants has been shown to decrease morbidities including severe ROP and infection, and to improve their neurodevelopmental outcome [25–27]. Another important outcome of this study was the effect of the FIC program on parental stress. The significant decrease in stress scores of FIC parents over their time in the unit (vs. no change in controls) suggests a benefit of the FIC program, which according to the parents enabled them to have greater confidence in their parenting skills on discharge from the hospital. The parents’ reflections on their experience also indicate that the program appeared to achieve what it was intended to do, that is to enable parents to participate in their infants’ medical care while in the NICU. Our anticipation of the need for greater parental education to allow them to take on this role was also noted. The acceptability of the model to nursing staff was also key to its success. Despite the small sample, the nursing interviews indicated that implementation of the FIC program allowed the role of nurses to shift from caregiver to facilitator and coach for parental involvement.
The study results may have been confounded by unmeasured variables, such as other causes of prolonged hospitalisation in the control infants. This is particularly worth considering in regards to the effects of the intervention on severe ROP. While there is some justification for why an intervention such as the FIC program might affect neuronal developmental, it is also possible that the control infants were somehow different. In terms of stress reduction among FIC parents, the persistently high stress scores in the concurrent control parents could possibly be attributed to their infants being sicker, which was not measured. Another limitation of this study was the use of critical incidence reports as the only measure to monitor safety. However, while statistical power was limited and other safety indicators were not measured, the number of critical incident reports is the main indicator system used by hospitals to monitor safety and the study results suggest that, at the least, there was no increase in critical incidents during the implementation of FIC.
A final limitation of this study is that the enrolled parents, although of a very broad demographic profile, may not have been representative of our NICU parents in general. Although we had 75% enrolment of those families we approached, we did not approach every eligible family in the NICU as we had so few beds available for the program. Thus, we cannot conclude that the results of this study are generalizable to all parents in all NICU settings. However the results are consistent with the literature, which indicates that modifications of the NICU environment and greater parental holding, attachment, and responsiveness can improve infant outcomes [28–31]. Feedback from the participants also indicates that shifting the role of parents from passive support to active caregiving is feasible in the Canadian setting; consequently, the FIC model merits further study.