Our findings highlight that parents experienced different, and at times multiple, pathways for feeling emotionally close to their infant. These pathways of emotional, physical, cognitive and social influences led to embodied feelings of parent-infant emotional closeness. We identified five important areas comprising significant events/actions/processes that facilitated and contributed to the feeling of emotional closeness: Embodied recognition through the power of physical closeness; Reassurance of, and contributing to, infant wellness; Understanding the present and the past; Feeling engaged in the day to day; and Spending time and bonding as a family.
These findings are, in one way unique, as to date no other study has specifically explored experiences of emotional closeness in parents of infants in NUs. Unlike parents of healthy and term infants, parents of preterm and newborn ill infants spend their early days together in a highly medical context, where the ‘ownership’ of the infant could be debateable [3, 22, 23]. Because of the infant’s medical demands, professional skilled care is needed and the ‘normal’ parental role may be reduced [3, 24, 25]. Furthermore, a disruption of the family, where parent-infant separation is commonplace, is a clear demarcation and signal that parents are not needed by their infant . Subsequently, parents of infants who need neonatal care, unlike those of term infants, start their journey from a subordinate position. Moreover, while all new parents can experience anxiety, parents of premature infants often have higher levels of stress and depression  due to real concerns over the infant’s viability. In our study, through adopting a salutogenic approach, we were able to identify that parents were able to develop different pathways to develop emotional closeness with their infants, despite the stress and challenges faced. These insights may help health professionals to identify and support the developing parent-infant relationship.
Numerous studies have shown the importance of physical closeness on parental well-being [2, 28], and in the last decade research has focused on and demonstrated positive effects of skin-to-skin contact (i.e. kangaroo care) on parent-infant outcomes [29, 30]. Feeley and colleagues  described the importance of contact such as touch for fathers to be able feel the joy of parenting. This supports our findings in which parents described seeing the infant, having eye-contact, touching and holding as significant experiences for feeling emotionally close.
Reassurance of the infant’s health and wellbeing also appeared to be vital for these parents. These insights thereby suggest that having faith and trust for the viability of the infant promotes parents’ feelings of emotional closeness. This does not mean that parents whose infant is terminally ill would not feel emotionally close, but that it is much harder and may take a longer time [3, 31]. Previous studies have found that when parents believe that their infant might die, they distance themselves from the infant, geographically and emotionally [3, 25]. Ongoing reassurance by staff on the infant’s clinical progress therefore appears crucial.
Another pathway to closeness involved parents performing day to day activities of their infant’s care. Our findings showed that feeling engaged was the result of providing ‘normal’ care for their infant and experiencing it as joyful. Furthermore, by being engaged, parents also experienced a growing sense of commitment. Indeed, Winnicott  stated “The mother’s pleasure has to be there or else the whole procedure is dead, useless, and mechanical” (p. 27). On a busy NU, staff members may forget that basic caretaking roles such as putting clothes on an infant for the first time is a significant and primary parental role. Our findings are in concordance with other studies, which show that parents need to be present on the neonatal unit, involved and feel that they are in charge of such activities [18, 33].
Our findings also showed the importance of how parent’s need to have an understanding and an awareness of their own experience and emotions in order to feel emotionally close. Parents often face surreal, chaotic and deeply distressing situations in the NU and the combination of parental issues and infant vulnerabilities can be especially difficult. Parents are not mentally prepared for the experience and may put their “life on hold”. This represents a strategy where they block their emotions and endure the situation with consequences of alienation – in regard to their own needs, from their infants or from being parents [9, 25]. A study by Coppola et al.  reported that more than 80 % of the parents felt the need to share their experiences during the time at a NU. However, parents might avoid disclosing and sharing experiences with others because of feelings of social isolation, guilt, shame and thinking that others do not understand. Hence, more research is needed in order to identify feasible and effective interventions that support parents emotionally, e.g. parent support groups [4, 35, 36]. Furthermore, the interpersonal relationships with staff are of crucial concern for feeling valued, respected and involved . One feasible approach to enable staff to support parents emotionally is to facilitate person-centred communication (PCC). McCormack and colleagues  have defined PCC as a model of care, which includes components such as: building mutual trust and understanding; treating the person as an individual; respecting the rights of the person, sharing decision-making, providing holistic care and developing therapeutic relationships. Within neonatal care, a randomised controlled trial was conducted to explore the effects of PCC on parental stress. The quantitative analyses showed no difference in terms of parental stress . However, the qualitative evaluation of the study showed that the components of the intervention (i.e. scheduled nurse-parent dialogues, semi-structured reflection sheets for parents to fill out and PCC) enabled the parents to discover and express emotions, gain a deeper form of communication and experience a mutual understanding (i.e. nurses gaining insights into the lives of the parents and parents understanding each other) .
An interesting finding in our study was that only the English and Finnish mothers described how breastfeeding facilitated feelings of emotional closeness. As this is a qualitative study and women were provided with an open brief to describe moments/experiences of closeness it may be that Swedish mothers did not consider breastfeeding to be such a significant act, or that they did not write about it. The lack of consideration of breastfeeding may also be contextual. The Swedish unit had a single room design and the English and Finnish units had open bay rooms. In a single room unit, staff may be less inclined to promote breastfeeding, as parents spend all their time with their infants. A previous study  showed that when parents had the opportunity to stay day and night with their infant, the ‘necessity’ of breastfeeding for becoming ‘a good enough mother’ attenuated.
Spending time together as a family was described by mothers and fathers as important for emotional closeness. Family Centred Care (FCC) is a philosophy, comprising a set of values, policies and approaches to services for infants and children with special needs and their families. The FCC approach places parents at the centre of care-giving processes and procedures [41, 42]. However, ‘parents’ often become synonymous with ‘mothers’, especially in healthcare of newborn infants. Internationally, there are wide variations in mothers and fathers presence in the NUs; fathers visit less and for a shorter time than mothers, and are less engaged in caretaking (e.g. infant cleaning and feeding) [26, 43]. Efforts need to be made to ensure that the design of the unit, as well as staff support of parental presence and engagement, enable both fathers and mothers to participate on equal terms. Furthermore, a ‘family’ may include many significant people (e.g. partners, siblings, grandparents) who are vital for parents’ emotional wellbeing. A design and philosophy in NUs where parents and the family are truly at the centre of care may be an important step to increase emotional closeness.
A potential limitation of the study is that there may have been an ‘elite-bias’; mothers and fathers who were more confident in expressing emotions in writing participated. However, the writing style and the length of ‘stories’ differed substantially. Furthermore, it could be that the risk for an ‘elite-bias’ is reduced when parent write their stories rather than tell them, especially when anonymous. Some parents completed the emotional closeness form on the first day after birth, while others completed the form two months after birth. This could reflect when the parents were recruited/invited to participate in the study and/or simply when parents wanted to. Regardless, from the insights captured, we believe that parents highlighted experiences that were prominent for them, a positive critical point during the hospital stay, regardless of when the event(s) occurred. To enhance credibility and trustworthiness . Swedish and Finnish stories were translated into English with comments explaining nuances and all authors were involved in the coding and analysis. While socio-demographic, cultural, NU design and policy differences may limit the transferability of the findings, similar issues were raised by parents from different countries and settings and who had infants of different gestational ages at birth. Further, more in-depth qualitative research (i.e. using interviews and/or focus groups) across different international contexts and with different population groups would help to authenticate the findings generated. Very rarely do researchers studying parenting of preterm infants write about joy and happiness. Hypothetically, more research with a salutogenic approach and/or on positive emotions would be beneficial and shed light on how to make improvements within neonatal care.