Parenting interventions in neonatal intensive care units take different approaches

Evidence-based parenting interventions have been developed to involve parents actively in their infant's care during neonatal intensive care. The final aim of these interventions is to improve developmental outcomes, especially for preterm infants. Therefore, this Special Issue invited the developers and expert users of parenting interventions for neonatal intensive care units (NICUs) to describe them in a way that allows comparisons. All interventions included parental support, but that was emphasised differently, as were the overall goals, content, mechanisms, modes of implementation and research outcomes. The interventions put different emphases on the infants' developmental needs and how the parents were supported and integrated into the care of the infant. The aims of the Newborn Individualised Developmental Care and Assessment Program (NIDCAP) and Supporting and Enhancing NICU Sensory Experiences (SENSE) are to support the development of preterm infants. NIDCAP uses individualised care plans, based on developmental assessments of an infant's behaviour,1 whereas SENSE enriches the preterm infant's environment by helping the parents to provide positive sensory experiences.2 The NIDCAP Federation also offers a nursery certification programme that underlines the importance of the environment as a source of sensory experiences for infants. The Newborn Behavioural Observations System (NBO) involves parents in real-time observations and its aim is to help them understand their infant's competencies, challenges and individuality.3 The Family Nurture Intervention (FNI) trains mothers to provide calming sessions for her preterm infant and strengthen their autonomic emotional connection.4 Family Integrated Care (FICare) and Close Collaboration with Parents both include unit-level interventions. FICare promotes parents as primary caregivers and integral members of the healthcare team, as well as policy changes and amenities for parental involvement.5 Close Collaboration with Parents improves the communication skills of the healthcare team, to enhance parental support and provide collaborative care.6 Parental roles differ between the interventions. Some are delivered by parents (SENSE, FNI), some support parenting and infant care (NBO, NIDCAP), while others integrate parents as partners in the care delivery (FICare, Close Collaboration with Parents).7 The parental roles may reflect when they were invented, as some were developed in the 1980s and others are more recent. Older programmes focus on the infant's behaviour and developing individualised care. Later programmes have increasingly focused on including parents in care. The most recent target units, with regard to the culture of family-centred care, staff knowledge and skills and unit policies to support parents. However, the infants' neurobehavioural functioning and sensory environment are central to all programmes. FNI also features autonomic emotional co-regulation and Close Collaboration with Parents adds the developmental psychology of parenting. We asked the authors to report how they implemented their programmes, as it is essential to understand this to evaluate complex interventions. All involve NICU staff in the implementation. NIDCAP provides 1–2 years of training so that some team members can become specialists, perform developmental assessments of infant behaviour and provide individualised developmental care recommendations. Assessments take 30–90 min and should be repeated weekly or bi-weekly. Self-evaluation is available at the unit implementation level.1 NBO provides 2 days of training and observation sessions that take about an hour and can be performed once or repeated.3 SENSE is primarily performed by the parents, but at least one staff member is trained to be a SENSE administrator, by reading the programme material and/or watching the introduction video. The administrators provide the parents with educational materials, assess the infant's ability to tolerate the intervention and make any individual modifications. This takes about 70 min during the infant's hospitalisation. Most units have implemented SENSE within 6 months.2 FNI is performed by the mothers in the presence of a nurse, who undergoes an unspecified amount of nurture specialist training, which includes evaluating the mother-infant emotional connection. Mothers delivered an average of 43 h of calming sessions during the infants' hospitalisation.4 FICare has a multi-component implementation process, which provides training for staff and parents. Implementation can take up to a year, or more and parental training sessions can vary from 30 min to several hours.5 Close Collaboration with Parents provides training for all NICU staff, including managers. Total implementation, including training local mentors, takes about 18 months. Each team member gets 36 h of training during the implementation, and then the intervention is integrated into everyday care.6 In summary, the programmes differ significantly with regard to the duration of training during implementation and the number and roles of individuals who are trained. Consequently, the implementation resources differ significantly. The amount of trained staff can impact the sustainability of the intervention and further research is needed to understand which elements are involved. Successful or efficient implementation may vary, depending on healthcare systems and how funding is provided. It is notable, that most interventions have been developed in resource-rich countries and involve costs for programme materials and training, or additional staff. The papers on the SENSE, FNI, FICare and Close Collaboration with Parents programmes examine implementation outcomes, such as acceptability, feasibility and fidelity. However, they mainly focus on implementation outcomes separately, rather than exploring their relationship to the primary outcomes for infants and parents. The process evaluation framework for complex interventions indicates that it is critical to study the implementation process,8, 9 to know whether any changes in primary outcomes are due to the intervention or unknown factors. Parenting interventions are typically designed to improve child outcomes and all of the interventions improved short-term infant outcomes, such as infant growth and medical recovery. NIDCAP, FNI and FICare have also demonstrated effects on long-term child outcomes. Despite this, the specific mechanisms that mediate positive infant/child outcomes remain unknown. Parental outcomes were measured by evaluation studies and mainly focused on mental health, such as stress, anxiety and depression. Although mental health affects parenting skills, we need to understand how interventions directly affect parenting behaviours. These include sensitive responses and caregiving (FNI), skin-to-skin contact and the parents' presence in the NICU (NIDCAP and Close Collaboration with Parents), co-regulation skills (FNI), parents' verbal communication and emotional connections with their infant and mentalisation. The proliferation, and benefits, of parenting interventions indicate great progress in the field and call for science-based understanding of how they work. We need to identify both the active ingredients of interventions and how they affect the proximal parenting outcomes, which are intrinsically linked to their effect mechanisms.10 None of the current interventions explicitly identified the proximal parenting outcomes and thus the following summary includes some of our interpretations. The infant behaviour observations and care recommendations given to parents appear to be the active ingredient in NIDCAP. Although parents are not routinely part of the observations, they receive written reports and engage in follow-up discussions. Therefore, the proximal parenting outcome could be their increased knowledge and understanding of their baby's cues, which affect their interactions. The active ingredient in the NBO is the infant observation sessions with the parents and the outcome is to strengthen parent-infant relationships. NBO has been related to better parent-infant interactions at 4 months of age, although not studied with preterm-born infants.3 SENSE's active ingredient is educating parents to perform sensory interventions so the proximal outcome is parental empowerment. Its effect on maternal confidence, which can be related to empowerment, has been demonstrated.2 FNI's active ingredient is the calming cycle between the mother and her preterm infant. It has been shown to positively affect proximal outcomes, such as physiological regulation, namely vagal tone, sensitive maternal caregiving behaviour and the emotional connection between the mother-infant dyad.4 Active ingredients of FICare are education, support and parental guidance and modified unit amenities. The proximal outcomes could be the primary caregiver experiences, improved knowledge and parenting self-efficacy. Self-efficacy was evaluated by a pilot study, but the small cohort did not allow for between-group comparisons.5 The active ingredients of the Close Collaboration with Parents programme are staff-parent communication and collaborative infant care and emotional support for parents. The proximal outcomes are parents being actively involved in communication, decision-making and their infant's daily care, which have been measured, and parenting self-efficacy. In summary, the differences between interventions are richness and they can provide support to different groups and parenting pathways. This variety makes it possible to combine several complementary interventions in one NICU. The current study designs include randomised control trials. One was a large cluster study and this design is suitable for large, complex interventions that cannot randomise individuals for ethical and practical reasons.11 The limitations of the current research are that the mechanisms of the interventions, and lack of implementation measures, such as adherence, doses and participant responsiveness, are not made explicit. These are needed for stronger evidence about causal pathways. FNI is exemplary in exploring mediating behaviours and parameters and testing direct intervention effects on parenting. It also presents a theoretical background for the mechanisms behind improved long-term child outcomes. Gaining more knowledge about the mechanisms and success of implementation would help decision-makers to target resources more effectively when developing their family-centred care practices. The evaluation studies were conducted in five continents, so the global coverage was good. However, a more in-depth view of how context affects implementation and the effectiveness of interventions is needed, as they may vary in different cultures and healthcare systems.12 Continued systematic evaluations of interventions will raise additional concerns. One is consistent delivery, as there are numerous variations, including how much time parents spend with their baby, their roles during rounds and their experience in providing bedside care. These examples help us to appreciate the complex care provided in NICUs and that those interactions are forces that can act on infants. The number and sources of likely forces are large and understanding them is daunting, but essential. Future research should involve more than researchers and clinicians, in developing and evaluating intervention programmes, notably parents and decision-makers.12 Reporting negative intervention effects is also important and a joint responsibility for researchers and publishers. In conclusion, NICU parenting interventions seem to be beneficial for both parents and their infants, even if there are knowledge gaps and interventions are based on different theoretical backgrounds. Sari Ahlqvist-Björkroth: conceptualization; writing – original draft; writing – review & editing; project administration. Nancy Feeley: writing – original draft; writing – review & editing. Jeffrey Alberts: writing – original draft; writing – review & editing. Rosario Montirosso: writing – original draft; writing – review & editing. Liisa Lehtonen: conceptualization; writing – original draft; writing – review & editing; project administration. No funding was received for this work. Sari Ahlqvist-Björkroth and Liisa Lehtonen are the developers of the Close Collaboration with Parents intervention.

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