A decade of change : the development of family centered care in a neonatal intensive care unit

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This thesis is about change in nursing practice in a neonatal nursery. It examines the process of change as the development of a family centered care (FCC) philosophy and practices are integrated into the nursing care within the Neonatal Intensive Care Unit (NICU) over a ten-year period. This is a qualitative study that uses case study methodology to examine and analyse the context and processes involved in achieving change in neonatal nurseries. The data used for the case study included, reports and publications from previous research projects relating to the development of a FCC philosophy in the NICU, interviews and focus groups held in 2001-2002 and in 2004-2005. A staged thematic analysis and confirmation process was used for the analysis. The data analysis and themes developed from the data indicate there has been change in practice over time in the involvement of parents in the care of their infant in the NICU. There is evidence that many of the nurses have moved from an expert framework to a framework in which a two-sided conversation between nurses and parents should and often does occur. The change is not complete as it an ongoing and dynamic process and the nurses recognised further ongoing issues relating to control, 'ownership' and resistance to change. The diffusion of innovation theory provided an appropriate framework to think about a change in nursing practice over time. It provides a structured approach to describing change in practice with emphasis on communication networks. The roles of opinion leaders and change agents are integral to the diffusion process. The neonatal nurses who participated in the study identified other useful strategies that assist in the change process. They specifically identified the importance of ongoing education, including, less didactic methods of teaching and learning, such as role modelling, mentoring, feedback, reflection and discussion of relevant experiences; policies and procedures to support the change, engagement and participation of staff through group development processes and summaries of written research evidence. The change to a FCC philosophy and practices in the NICU is an ongoing journey that has taken considerable time. The rate of acceptance of FCC as an innovation in practice has been effected by a number of factors. These include, the readiness of the nursing staff to change, the attitudes and role perceptions of nurses and parents about their boundaries of care and responsibilities for the wellbeing of the infant, the lack of consistency and shared understandings in the clinical judgment and decision making process, and the nurses skills to engage and enable parents in parenting their child in a relatively foreign and 'hostile' environment such as the nursery. The implications for clinical practice include the recognition of the necessity for maintenance strategies to be developed in the NICU to ensure practice remains at the same level and does not slip back, a possible strategy could include clinical supervision or reflective practice groups. In addition, it is apparent that there is a need to continue to work towards integration of FCC philosophy and practices into the clinical practice of all nursing staff. The establishment of a working group of interested staff to continue the development of FCC philosophy and practices and to develop strategies to overcome any remaining barriers may be appropriate. Finally, education needs to continue covering topics such as Kangaroo Care (KC), FCC philosophy and practices, and communication skills.
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