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Integrative Review
Ashton Birdsong
NUR 4122
April 2, 2019
Abstract
The purpose of this integrative review is to examine research literature that evaluates the
correlation between family involvement in neonatal and pediatric critical care settings and
patient outcomes. Previous research indicates that the use of the Family Centered Care (FCC) in
critical care settings leads to favorable outcomes. However, further improvements are still
pursued to improve patient outcomes, parental experiences and decrease length of stay. The
PICO question under consideration is: Does increased family involvement influence length of
stay and patient outcomes in patients placed in PICU/NICU settings? The research design is an
integrative review. The databases used to locate research articles were EBSCO CINAHL and
Pub Med. The results yielded 730 articles and five met the inclusion criteria. The findings and
results of the five reviewed studies indicate a positive effect of implementing family-centered
care practices in NICU/PICU settings and that increased parental involvement has positive
impacts on their child’s well-being. Limitations to the review include lack of experience of the
researcher, limited time to complete the assignment, and limited number of articles for the
review. The implications of these findings suggest there are positive benefits of implementing
increased family-integrated care not only to critically ill children, but their parents as well.
Recommendations for further research include exploring the impact on individual family
members, different gestational age, and level of parents’ active role during their child’s care.
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Integrative Review
The purpose of this integrative review is to examine research literature that evaluates the
correlation between family involvement in neonatal and pediatric critical care settings and
patient outcomes. Family-Centered Care has been previously researched and results indicated
favorable effects on infants, children, and their families, by decreasing anxiety and depression,
increasing parental confidence and competency, and promoting the development of early
interaction (Raiskila, 2014). With recent developments in improved treatment practices, modern
equipment, and more effective clinical practices, mortality and morbidity rates have decreased
immensely in intensive care units across neonatal and pediatric populations. However, further
improvements are still pursued to improve patient outcomes, length of stay, and parental
experiences (Broom, 2017). Parents are vital players in providing sufficient emotional, social,
and physical support for their children to promote proper development during their hospital stay
and past their recovery (Raiskila, 2014). The aim of the review is to examine and discuss
previous research information as it relates to the researcher’s PICO question: Does increased
family involvement influence length of stay and patient outcomes in patients placed in
PICU/NICU settings?
The research design is an integrated review. The articles were researched utilizing two
search engines, EBSCO CINAHL and Pub Med. The search terms included, ‘family
involvement’, ‘PICU’, ‘NICU’, ‘length of stay’, ‘outcomes’, and ‘parental presence’. The results
yielded 541results from EBSCO CINAHL and 189 results from Pub Med. To ensure a current
approach of the issue, the search was limited to peer-reviewed qualitative and quantitative
nursing research journal articles, published in English, and written between 2014-2019. The
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articles had to pertain to the researcher’s PICO question, “Does increased family involvement
influence length of stay and patient outcomes in patients placed in PICU/NICU settings?”
Furthermore, the research articles were selected based on the following inclusion criteria:
pediatric or neonatal intensive care population, patient outcomes, parental involvement, length of
stay, and family-centered care. The research articles that did not include the above criteria, were
excluded. The screening produced a total of five articles, three quantitative and two qualitative.
The findings and results of the five reviewed studies all indicate a positive effect of
implementing family-centered care practices in NICU/PICU settings and that increased parental
involvement has positive impacts on their child’s well-being. A summary of the research articles
is attached via Appendix 1. The researcher outlined the review according to the following
themes: positive impact family-centered care (FCC) has on patient outcomes and parental
perceptions.
Two of the five research articles utilized quantitative studies to determine the correlation
between FCC and positive outcomes in NICU/PICU patients (Raiskila, Axelin, Rapeli, Vasko &
Lehtonen, 2014). & O’Brien et al.,2018). In a study conducted by Axelin et al. (2014), the
authors researched the development of care practices that enable parental closeness and parental
participation in the NICU setting. This retrospective study reviewed 295 charts of very preterm
infants born at less than 32 weeks gestation or born with a weight less than 1500 grams in Turku
University Hospital over an 11-year span. The methods of research for this study included a
retrospective review of infant’s medical charts, using their gestational age, birth weight, and
which included incubator time, enteral and oral feeding practices, which focused on
breastfeeding practices, and lastly parent-infant skin-to-skin care practices. After the data was
collected, analysis of covariance was used to further study associations between outcome
variables. Results indicated that hospital care practices of very preterm infants that supported
and enabled better parental involvement showed a positive correlation to increased preterm
improvements in their weight gain. These findings served as indicators of progressive trends in
FCC, highlighting the notable discoveries regarding skin-to-skin care and breast-feeding.
The second quantitative study completed by Kariel O’Brien et al. (2018), studied the
effect of integrating NICU parents into their child’s health-care team and aimed to analyze the
effect FCC had on infant and parent outcomes, safety, and resource use. This multicentered-
cluster, randomized control trial was comprised of 26 NICUs from Canada, Australia, and New
Zealand. The NICUs were randomly selected to either provide Family Integrated Care (FICare)
or to provide standard NICU care. 895 infants were placed in the FICare group and 891 were
placed in the standard NICU care group. Infants were considered eligible if they were born at 33
weeks gestation or less, and no or low-level respiratory support. Parents were required to commit
to being physically present for at least six hours a day while also attending education sessions
and actively caring for their infant. The primary outcome measured was the infants weight at day
21 after enrollment. Secondary outcomes measured were weight gain velocity, high frequency
breastfeeding, parental stress and anxiety at enrollment and day 21, NICU mortality and
morbidity, safety, and resource use. Data was analyzed using linear regression for continuous
variable and logistic regression for categorical variables. The researchers found that the use of
FICare is a vital advancement in neonatal care as evidenced by improved infant weight gain,
decreased parental stress and anxiety, and increased breastfeeding exclusivity at discharge.
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Parental Perceptions
Three of the five research articles studied the effect parental perceptions and participation
have on family-centered care (Aija, Toome, Axelin, Raiskila & Lehtonen, 2019; Broom, Parsons,
Carlisle & Kecskes, 2017; & Hill, Knafl, Docherty & Santacroce, 2018). The quantitative multi-
centered prospective study conducted by Aija et al. (2019) evaluated the degree of parental
participation in medical rounding as well as aiming to identify family and hospital characteristics
that may facilitate or hinder parental integration into medical rounds. The study was comprised
of a total of 241 NICU families from 11 European countries. Parents were considered eligible if
their infant was born preterm before 35 weeks gestation. Questionnaires were given to parents at
discharge to measure parent and infant characteristics and unit characteristics. Data was collected
via a series of randomized text messages sent out every evening that asked parents a series of
questions that covered aspects of FCC like active listening, parental participation, individualized
guidance and participation, shared decision-making, emotional support. The data was analyzed
using descriptive statistics that characterized infants and families using a seven point Likert
Scale rating their participation. The results indicate that parental involvement in medical rounds
is variable depending on location globally. The factors increasing parental presence during
medical rounding differed based on unit policies, an overall invitation to parents into rounding
discussions, higher gestational age of the infant, and higher education of the father.
Margaret Broom et al. (2017) completed a qualitative focus group study evaluating the
impact of FCC models have on encouraging active parental participation in their infant’s care
and the model’s influence on decreasing parental stress and increasing parental competence. The
sample was comprised of 16 families who had participated in Family-Integrated Care (FICare)
during their first six months along with 80 staff members in an Australian level 3 NICU. The
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data was retrieved from two focus groups: one for parents and one for staff. Audio recordings
were taken during the focus groups then transcribed afterwards. Each transcript was reviewed
using thematic content analysis following a qualitative descriptive approach. Transcripts were
then read by two members of the study team who determined themes repeated throughout the
context, which were highlighted and created into a detailed outline. The findings indicated that
both parents and staff found the FICare to be very beneficial. They found the program to have a
positive impact on parental confidence and role attainment, while also improving communication
between both parent-to-parent and parent-to-staff. Staff spent more time educating and
supporting NICU parents, which led them to perform less hands- on care.
Lastly, in the qualitative descriptive study by Hill et al., (2018), researchers studied the
parental perception on impact of physical and cultural environments in the PICU have on the
successful delivery of FCC in pediatric critical care settings. The sample was comprised of a
total of 61 interviews with mothers and fathers of infants with complex congenital heart defects
treated in the PICU. The data was retrieved from secondary analysis based on previous interview
data on a longitudinal study that examined parental experiences with core concepts of FCC and
how the physical and cultural environment influenced their overall PICU experience. Those core
concepts included information sharing, participation, respect and dignity, were all implemented
by their care team. Careful review of interview transcripts for each case was done to collect the
above data. The data was then analyzed by direct content analysis that coded the data which was
followed by a review to identify parental experiences and their relationship to physical and
cultural environments. Results indicated that both physical and cultural environments impacted
their perceptions on how core concepts were implemented by their care team.
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The studies reviewed provide insight and awareness into the question,does increased
familial involvement influence length and stay and patient outcomes in NICU and PICU
patients? Practices that supported parental involvement in their infant’s care significantly
improved very preterm infant weight gain (Raiskila et al., 2014 & O’Brien et al., 2018). Findings
also suggest that increased parental involvement and inclusion benefits many psychosocial
aspects parents may feel, like increased confidence and competence (Broom et al. 2017 & Aija et
al., 2018). Parental perceptions of their child’s critical care environment was also studied and
found that the physical and cultural environment of the intensive care unit was shown to both
contribute to and alleviate parental distress (Hill et al., 2018). The implications of these findings
suggest there are positive benefits of implementing. Recommendations for further research
include exploring the impact on individual family members, different gestational age, and level
Limitations
This integrative review has limitations present that should be noted. Given that only five
articles were used for this class assignment, it cannot be considered an exhaustive review. The
articles used in this review were written within the last five years, so they cannot be generalized
Broom et al. (2017) determined that a small focus group size elicited a broad range of
opinions on the benefits of FICare program. Because of the secondary analysis method used in
C. Hill et al. (2018), researchers were unable to control the course of the interviews and research
further into more data that related to the study’s specific aims. The study design of Raiskila et
limitation was the charts that were reviewed were handwritten, microfilmed, and scanned,
making the documentation of care practices inconsistent. Regarding the study that implemented
the use of text messages, researchers Aija et al., (2019) encountered some technological
difficulties sending text messages in certain countries, which resulted in missing data. Data was
also missing in research by O’Brien et al., (2018) due to increased rates of transfers to level 2
Conclusion
The relationship between parental involvement in the PICU/NICU setting and patient
outcomes is discussed throughout this integrative review. Results indicated a positive correlation
with increased parental involvement and their child’s physical well-being, as well as improving
many psychosocial aspects of parents’ perceptions and experiences in the critical-care setting.
Despite substantial evidence on the correlation on length of stay and parental presence, evidence
supporting improved weight gain can lead to the assumption that length of stay is affected. The
findings in this integrative review implicate the importance of parental involvement and
integration of family-centered care by staff in critical care settings of young loved ones.
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References
Aija, A.,Toome, L., Axelin, A., Raiskila, S.,& Lehtonen, L. (2019). Parents’ presence and
Broom, M., Parsons, G., Carlisle, H., & Kecskes, Z. (2017). Exploring parental and staff
Hill, C., Knafl, K., Docherty, S., & Santacroce, S. (2018). Parent perceptions of the impact of
the pediatric intensive care environment on delivery of family-centered care. Intensive &
O’Brien, K., Bracht, M., Cruz, M., Lui, K., Alvaro, R., da Silva, O., Monterrosa, L., Narvey, M.,
Ng, E., Soraisham, A., Ye, X., & Mirea, L. (2018). Effectiveness of family integrated
care in neonatal intensive care units on infant and parent outcomes: a multicenter,
Raiskila, S., Axelin, A., Rapeli,S., Vasko, I., Lehtonen, L. (2014). Trends in care practices
reflecting parental involvement in neonatal care. Early Human Development (90) 863-
Appendix
Article Reference Aija, A.,Toome, L., Axelin, A., Raiskila, S.,& Lehtonen, L.
(2019). Parents’ presence and participation in medical rounds in 11
European neonatal units. Early Human Development, 130 10-16.
Doi:
Background/Problem Background: Care practices that encourage parent-preterm infant
Statement closeness have been proven to improve overall development of
preterm infants. Many positive outcomes have been found to be
resulted from increased parental involvement in NICU’s, yet there
has been little research assessing parent’s perspectives on their role
in decision making in the NICU setting.
This study does not particularly address the PICO question well
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Article Reference Broom, M., Parsons, G., Carlisle, H., & Kecskes, Z. (2017).
Exploring parental and staff perceptions of the family-integrated
care model: a qualitative focus study. National Association of
Neonatal Nurse. Doi:
Background/Problem Background: Throughout recent decades, NICU’s worldwide have
Statement utilized forms of Family-Centered Care (FCC) models, where
healthcare professionals encourage and support families to be more
involved in their infant’s care. This has been proven to make
parents/family members feel more confident and empowered in
treating and caring for their infants.
Problem Statement: The purpose of this study was to evaluate the
impact of FCC models developed by NICUs in encouraging active
parental participation in their infants care and the FCC models’
influence on decreasing parental stress and increasing parental
competence.
Conceptual/theoretical None
Framework
Design/ Design: Qualitative
Method/Philosophical
Underpinnings Methods: Focus Group (open-ended questions)
Sample/ Setting/Ethical Sample: Focus group of 16 families who had participated in the
Considerations FICare program during the first 6 months; 80 staff members were
asked to participate
Measurement Tool/Data Measurement Tools: 2 focus groups – one for parents and one for
Collection Method staff members
This study does not particularly address the PICO question well due
to the focus being primarily on the parental outcomes versus the
patient (infant) outcomes.
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Article Reference Hill, C., Knafl, K., Docherty, S., & Santacroce, S. (2018). Parent
perceptions of the impact of the pediatric intensive care environment
on delivery of family-centered care. Intensive & Critical Care
Nursing (50) 88-94. DOI:
Background/Problem Background: The Institute for Patient and Family-Centered Care
Statement (IPFCC) states that parents are vital members of the partnership
that is needed to ensure the successful delivery of FCC in
pediatric critical care settings. With an increased push for
pediatric care to be more family-centered, parent perceptions on
the delivery of FCC care is critical to the advancement of care.
Major Variables Studied Quantity and depth of information related to FCC contained
(and their definition), if in parent interview data
appropriate Informational variability based upon time of diagnosis
Length of PICU stay
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This study does not particularly address the PICO question well due
to the focus being primarily on the parental outcomes versus the
patient (infant) outcomes.
INTEGRATIVE REVIEW 18
Article Reference O’Brien, K., Bracht, M., Cruz, M., Lui, K., Alvaro, R., da Silva, O.,
Monterrosa, L., Narvey, M., Ng, E., Soraisham, A., Ye, X., & Mirea,
L. (2018). Effectiveness of family integrated care in neonatal
intensive care units on infant and parent outcomes: a multicenter,
multinational, cluster-randomized controlled trial. Lancet Child
Adolescent Health (2): 245-254 DOI:
Background/Problem Background:
Statement Problem Statement: The purpose of this study is to assess the effect
of integrating NICU parents into their child’s health-care team. By
doing so, there are positive correlations of parental-infant interaction
on infant weight gain, breastfeeding rates, and parental stress levels.
Conceptual/theoretical None
Framework
Setting: NICU’s in Canada (18), Australia (6), and New Zealand (1)
Major Variables Studied Primary outcome – infant weight at 21 days after enrollment
(and their definition), if Secondary outcomes – weight gain velocity (data collected a
appropriate beginning of enrollment, day 7, day 14, and day 21); high
frequency breast feeding at hospital discharge (6 or more
feeds/day); parent stress/anxiety at day 21; NICU mortality
and major morbidities; safety and resource use (oxygen
therapy and duration of hospital stay)
Measurement Tool/Data Measurement Tools: Parent stress/anxiety were measured using the
Collection Method Parental Stress Scale questionnaire (PSS: NICU) and the State Trait
Anxiety Index (STAI)
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Article Reference Raiskila, S., Axelin, A., Rapeli,S., Vasko, I., Lehtonen, L. (2014). Trends
in care practices reflecting parental involvement in neonatal care.
Early Human Development (90) 863-867. DOI:
Sample/ Setting/Ethical Sample: 295 of very preterm infants born at less than 32 weeks
Considerations gestation or had birth weight less than 1500 g