Introduction

Traditionally, standard care involves separating newborns and mothers when they require special treatment postpartum.1 This practice can potentially challenge the establishment of early connection through physical and emotional closeness and family formation in the initial days following birth.2 In 2014, Bergman introduced the concept of zero separation3 which involves maintaining continuous skin-to-skin contact with one parent or ensuring that a parent is always present with the newborn. Zero separation promotes an infant-centred and family-centred developmental care approach that ensures constant parental presence with newborns, irrespective of health issues.4 Moreover, it fosters a collaborative partnership between parents and healthcare professionals (HCPs), positioning parents as primary caregivers and equal partners in the neonatal care team.5 Numerous studies highlight the positive effects of skin-to-skin contact with newborns including reduced mortality rates, lower infection risks, effective heart rate and thermal regulation and for mothers, encouraged breastfeeding and reduced stress through minimal separation.6–13 Recent research and WHO guidelines advocate for immediate and uninterrupted skin-to-skin contact for all newborns regardless of medical needs even before achieving ‘clinical stability’.14–16 These recommendations aim to ensure that mother and newborn stay together during the crucial early period even when specialised care is required and emphasise an oxytocin-centred approach in perinatal healthcare.17

Despite the evolving of care towards zero separation1 3 and the increasingly evidence supporting its importance, there is a need for research and descriptions on how to achieve this new organisation.18 ,19

To support zero separation, a new concept for organising the treatment and care of mothers and newborns is emerging in neonatal care and obstetrics. Mother–newborn couplet care involves providing care for both the ill mother and her ill or preterm newborn in the same room regardless of the care level or location during the first critical hours or days when both need treatment.20 The preferred method for newborns requiring less intensive care has been to treat both the newborn and mother in the same room with a single nurse providing couplet care for both.20–27 However, when highly specialised care is needed for both the newborn and mother, an alternative couplet care model is required.28 29 This model involves providing care and treatment in the same room with neonatal nurses caring for the newborn and obstetric nurses or midwives caring for the mother, ensuring the highest level of specialised care for both patients. Mother–newborn couplet care represents a paradigm shift in postnatal care and holds great significance for HCPs.3 Rooted in the belief that maintaining immediate and continuous contact between mothers and their newborns even when both require medical attention, this approach to care is expected to profoundly benefit both the mother and newborn. A gap has been identified between the current training and attitudes of HCPs and the practical requirements for keeping newborns and mothers together, regardless of the medical needs of both.30

Implementing couplet care in a highly specialised setting such as our neonatal and obstetric departments requires a new collaborative approach with education playing a crucial role in supporting the process. The attitudes, education level and leadership guidance of HCPs are key factors in successful implementation. Given the importance of their perspectives in curriculum development, we aimed to involve HCPs in the pre-implementation phase.31 Additionally, we sought to identify possible facilitators and barriers for HCPs as complex interventions within the healthcare system must consider the context when changing attitudes and work practices in a new healthcare organisation.32

The present study aimed to explore HCPs’ expectations, concerns and educational needs related to couplet care. The research questions were:

What are HCPs overall expectations toward couplet care, caring for mothers and newborns together in the same room regardless of the medical needs of both?

What possible barriers and enablers do HCPs predict?

What are the possible cultural differences between neonatal and obstetric departments that can influence collaborative teamwork?

What possible educational needs do HCPs identify?

MethodsDesign

We conducted a qualitative descriptive study33 based on four semistructured focus group interviews that we analysed using reflexive thematic analysis.34 This design seemed appropriate for including social interaction, describing the target population’s perceptions and experiences and understanding complex events within the human context.35 36 We chose focus groups since we aimed to generate data on interpretation, interaction and norms among various HCPs.37 38 For quality assurance, we report the results in accordance with the consolidated criteria for reporting qualitative research.39

Setting

We conducted the study at Copenhagen University Hospital—Rigshospitalet in Denmark at the departments of neonatology and obstetrics. The former department is a level IV neonatal intensive care unit (NICU)40 that provides highly specialised treatment and care for the most complex and critically ill newborns, admitting approximately 1200 newborns annually. The latter provides treatment and care for mothers with uncomplicated to severe obstetrical complications including high-risk referrals from all of Denmark, admitting approximately 6000 mothers annually. When both the mother and newborn require treatment and care, they are admitted separately, the mother receiving obstetrical care at the department of obstetrics and the newborn neonatal care at the department of neonatology. In 2026 both departments will relocate to the new Mary Elizabeth’s Hospital—Rigshospitalet for Children, Teens and Expecting Families,41 which will have single-family rooms. Part of the ambition of the new hospital is to keep the mother and newborn together for treatment and care in either the neonatal department or the obstetric department. The final organisation regarding the physical location for mothers and newborns and the staffing arrangements around them has not yet been decided. In this study, we asked the HCPs to relate to couplet care in either the neonatal department or the obstetric department with a neonatal nurse caring for the newborn and an obstetric nurse or midwife caring for the mother.

Participants

21 HCPs spread across both departments participated in the intervention and were divided into groups for four focus groups (see figure 1 for the inclusion flowchart). The sample size was set to ensure a broad yet manageable representation for analysis following recommendations that six to eight participants per group allow for in-depth discussions.37 The leaders of the two departments pointed out possible participants. Inclusion criteria: Neonatologists, obstetricians, midwives and neonatal and obstetric nurses with various levels of postgraduate experience. The rationale behind these criteria was a desire to achieve rich and detailed information focusing specifically on issues central to the aim of the study.42 We made an effort to maintain a balance between senior and junior staff across all HCP groups using a purposeful sampling strategy.42 Further, we anticipated that assembling heterogeneous groups would contribute to the richness of data through the collaborative process of coconstruction. Participants’ demographics are presented in table 1.

Figure 1

Inclusion flowchart composition of four interprofessional groups participating in focus group interview.

Table 1

Demographic characteristics of participants (n=21) in four focus groups recruited among 32 invited healthcare professionals

Data collection

The focus groups took place in June 2023 in a quiet room at the department of neonatology. A moderator, observer (JNL), co-moderator and interviewer (LB) led the focus groups. We used a thematic interview guide with open-ended questions to ensure consistent procedures33 and coverage of the research questions. We anchored the interview guide in participant expectations, concerns and educational needs related to couplet care for mothers and newborns. The interview guide is provided in box 1.

Box 1 Interview guide developed based on discussions in the research teamIntroduction:

Describe your preliminary expectations toward couplet care, caring for a sick mother and her sick newborn together in the same room.

Expectations/concerns:

What do you think it will be like for the family?

What will it be like for you as a healthcare professional (HCP)?

What kind of possible challenges do you expect? What can contribute to a good process?

Is anything of particular importance for you in the process?

Culture:

Can you describe how you see your role as a professional while collaborating in rooms for couplet care?

Collaboration:

Can you describe what is particularly important for you by virtue of your expertise?

How do you expect the implementation to influence collaboration between the two departments?

Education:

Do you see a need for the education of HCPs before implementation?

Education:

Which particular professional skills are required?

What kinds of situations should you possibly train in advance?

What is needed for you to work safely in rooms for couplet care?

Others:

Is there anything you would like to elaborate on? Anything you would like to add?

We conducted member checking on the spot by verifying their information.43 We took field notes during and after each interview and used them in the data analysis.44 Conducted in Danish, the interviews were audio-recorded, transcribed verbatim by a research assistant and lasted 1.5 hours on average, each one lasting as long as it took to gain a full understanding of participant perspectives concerning the study aim.45

Analysis

We used NVivo V.14 to code the transcripts and identify key cross-cutting themes related to the interview topics. Data analysis was conducted inductively through reflexive thematic analysis,34 46 emphasising the researchers’ active role in theme generation rather than simply uncovering them from the data. Multiple researchers were involved to ensure a collaborative, reflective approach for richer interpretations.47 Our six-phase process began with the familiarisation of data where JNL read and noted initial ideas. For trustworthiness, JNL independently generated initial codes and LB coding for two interviews. The research team discussed discrepancies, integrating coding frameworks. Themes were developed by organising codes and JNL and LB reviewed and refined these until agreement was reached. Themes were reviewed and revised collaboratively, ensuring saturation and mutual exclusivity. Finally, JNL drafted the report which all authors critically reviewed and approved for publication. Table 2 provides an example of the analytical process.

Table 2

Example of analysis of meaning units, content and themes

Researchers’ backgrounds

JNL, who has a degree in critical care nursing, has been a neonatal nurse for 13 years and has experience with teaching and mentoring in pregraduate and postgraduate nursing and intensive care nursing. LB, who has worked as a deputy chief midwife, add extensive leadership experience and years of research experience. The rest of the author group represents the obstetric and neonatal medical fields and have diverse professional backgrounds as an anthropologist (LEN), nurses (HH, RM), a neonatologist (PP) and an obstetrician (JLS), all of whom have years of research experience that strengthened the study design and analysis.

Patient and public involvement

During the protocol designing for the comprehensive research project including this study, we invited a parent of a previously admitted newborn to read and comment on our protocol. The comments did not lead to any major adjustments in this study.

Results

We identified the overarching theme of building bridges in relation to HCP’s expectations, concerns and educational needs and five subthemes: Enhancing meaningfulness through increased teamwork; compromising or improving patient safety; challenging professional comfort zones; encountering other cultural and ethical values; and recognising educational requirements. Themes, subthemes and contents are listed in table 3.

Table 3

One overarching theme and five subthemes identified related to HCPs’ expectations, concerns and educational needs

Subtheme 1: enhancing meaningfulness through increased teamwork

I think it’s essential to unite newborn and mother in the same room because you’re [nurses] present in the room and know what is going on for both newborn and mother, and you can turn to your colleagues to ask if something wasn’t clear. (P12, nurse, neonatal)

The HCPs described a desire for closer collaboration between the departments. They discussed the benefits of bringing the family closer together including how it might impact their job satisfaction. A better understanding of the mother’s and newborn’s conditions could add to a positive working environment. The information would be shared collectively and the HCPs, working together side by side in the room, could benefit effortlessly without spending time collecting this information elsewhere. For instance, giving mothers information and encouragement to express milk postpartum is an overlapping task between neonatal and obstetric HCPs that would flow more smoothly in a shared room.

Sometimes I think it’s a bit strange to do rounds for a mother when I have no idea how her newborn is doing. I mean, when I enter her room, not showing her empathy or care somehow feels disjointed if her newborn is very sick. (P10, obstetrician)

In addition to practical information, HCPs described the advantages of having information about both mother and newborn. With a comprehensive understanding of the challenges both mothers and newborns face, HCPs could express their sympathy more appropriately and enhance support for the whole family. They described that gaining more in-depth knowledge in each specialty about common diseases and treatments for mothers and newborns would be valuable and meaningful. Transitioning from fragmented care to a more holistic approach, considering the perspectives of both mother and newborn, might contribute to a more meaningful and fulfilled working environment for HCPs. The informants expressed a need for a deeper and shared understanding of the challenges faced by both patients to support a more fulfilling care and treatment process.

But we miss the parents here [NICU] because the father plays a significant role and spends a lot of time walking back and forth between the departments, losing skin-to-skin contact with the newborn. We [neonatal nurses] often call the obstetric department to ask how the mother is doing. Because you’re just thinking, how’s everyone doing? (P16, nurse, neonatal)

The informants expressed that reducing the unintended consequences of separation, supporting early and continuous skin-to-skin contact and keeping the mother, newborn and the other parent in the same physical room might also increase the sense of security for both families and staff. The HCPs wish to ensure better coherence and continuity in patients’ progress and believe that bringing the family together could contribute to achieving this. Closer collaboration could support knowledge sharing across specialities and achieve a broader and more comprehensive understanding of the process for both mother and newborn.

The statements reflect a systematic challenge in the healthcare system where treatment and care are often experienced as divided into silos corresponding to different specialities. Integrating care and treatment for both mother and newborn challenges traditional structures and requires a more collaborative care model that embraces a holistic approach and an enhanced understanding of both patients. This represents a shift from task-based interactions to a more empathetic and integrated approach to treatment and care. It is also important to consider that the well-being of both the mother and child is interdependent and separation disrupts the family’s and HCPs’ ability to provide cohesive care.

Subtheme 2: compromising or improving patient safety

It’s essential to realise that there might be potential for positive things—besides the obvious advantages for the family. If the mother has an infection, and both mother and newborn receive treatment, sharing information about the test result from the culture from the mother and targeting the antibiotics for both might be faster when they’re together in the same room … instead of waiting for HCPs to randomly find out from the files.(P8, neonatologist)

Patient safety was of significant topic in the focus groups. HCPs expressed concerns about potentially compromising the standard of care and treatment for mothers and newborns when bringing them together for couplet care. HCPs considered how various factors such as noise, having numerous people in the room, critical situations and the physical design of the room could influence the mother and newborn’s need for rest and a peaceful environment. Simultaneously the HCPs’ expressed a need to quickly access equipment and have a suitable workspace. One possible solution that we discussed was to divide the rooms, for example, with a transparent sliding door to provide severely ill mothers with a quiet space when needed while helping to shield the sick newborn from excessive noise, light and disturbances when the mother requires more highly specialised treatment and care. This approach could also aid HCPs in maintaining the necessary workspace, particularly in critical or acute settings. This solution might compromise the couplet care concept since this will separate the mother and newborn. Even though they are in the same room, they are not continuously close. There is a need to consider alternative solutions to achieve the need for rest and recovery without physical separation. The solution with sliding doors might also result from HCPs trying to secure an area for specific neonatal or obstetrical competencies knowing that they would not be challenged to consider the needs of both patients.

Differences in hygiene standards were also a concern, especially considering that the neonatal department requires a higher level of hygiene to protect newborns from infections which might be compromised in rooms for couplet care. Many suggested initiating the implementation of couplet care by starting with mothers and newborns requiring less intensive care to develop the necessary skills and experience in this setting before including patients in need of highly specialised care and treatment. On the other hand, couplet care may also enhance patient safety. HCPs noted that mothers often prefer to stay with their newborns in the neonatal ward for as long as possible and are reluctant to leave when they need to go to the obstetric ward for treatment and care. They pointed out that this delay can lead to compromised standards of care. For example, delayed pain treatment can result in unnecessary pain breakthroughs just as delays in detecting high blood pressure or fever can affect the mother’s treatment.

Subtheme 3: challenging professional comfort zones

I think it’s a concern that you suddenly find yourself being responsible for both [mother and newborn]. (P19, nurse, neonatal)

We have different responsibilities; we shouldn’t train in each other’s specialties. You must be strict about the boundaries. If the mother needs something, you must call for the midwife or obstetric nurse. And sometimes you feel that you know more than you do or that you—with the best intentions—say something that turns out to be incorrect. (P17, obstetrician)

HCPs expressed concerns about collaborating with their colleagues and the parents inside the rooms for couplet care; feeling like professional outsiders when forced to manage situations in a different specialty; and being taken out of their comfort zone. They voiced worries about working with new colleagues unfamiliar with the sense of security typically found in their own department. The HCPs said that identifying their teamwork roles was of great importance, also due to concerns about being uncomfortable in situations outside their specialised areas of care. Everyone agreed on the need to divide the care and treatment of the mother and the newborn among the HCPs. They deemed this necessary because gaining new care skills would be challenging in such a highly specialised setting and impossible to manage due to time and resource constraints. These concerns are mainly centred on professional interfaces. HCPs were uncertain about what their colleagues and parents expected of them in vaguely defined situations. Obstetric nurses and midwives were uneasy about parents possibly expecting them to provide answers to questions about the newborn’s condition or even to respond to alarms concerning the newborn. On the other hand, neonatal nurses were apprehensive about questions and expectations related to the mother’s condition. They imagined that a sense of insecurity might arise in the room if they were unable to assist, potentially compromising safety. Resources constraints in the Danish healthcare system caused the HCPs to raise concerns in every interview about allocating the necessary staff to couplet care. They suggested that standardised guidelines, aligning expectations and implementing separate alarms for neonatal and obstetrical assistance could strengthen the individual HCP’s overall sense of professional security.

I think it might be a good idea to involve a small group [of HCPs] to do a pilot test before involving everyone … and participating must be their own decision. (P9, midwife)

Feeling secure also relates to issues concerning psychological safety. Since where rooms for couplet care will be implemented is still undecided, HCPs conveyed concerns about working in unfamiliar surroundings. For example, they speculated about whether an uneven balance in rooms between neonatal and obstetric HCPs might put one group in the minority, leading to feelings of social unease, uncertainty about who to talk to during breaks and not feeling a sense of belonging. Many suggested that having a smaller group of HCPs assigned to work with couplet care would allow them to become better acquainted, develop routines and establish workflows more efficiently than if everyone was involved in the implementation. Reorganisation occurred primarily among the nurses and the physicians were more willing to conduct ward rounds in a different department. The physicians mentioned the idea of holding joint conferences between obstetric and neonatal teams to become more familiar with one another and each other’s specialities.

A cohesive unit, therefore, places significant demands not only on the physical environment but also on the HCPs who must navigate unfamiliar territory. Their uncertainty about what their colleagues and parents expect from them along with their suggestions for standardised guidelines indicates a considerable burden of responsibility associated with the merging of departments which is accompanied by significant fear and uncertainty.

Subtheme 4: encountering other cultural and ethical values

I haven’t thought about that actually … that not all newborns survive, even though I’m aware of it … Nurses who work in the maternity ward aren’t interested in the acute setting like you [neonatal nurses] are … it’s like two different personae, like in our DNA, and working in the maternity ward, you never picture yourself holding a stillborn. P2 (nurse, obstetric)

The HCPs may experience some differences between the cultural and ethical values in the two departments. In the focus groups, they discussed that HCPs would never ignore the other department’s patients but that their primary focus would be on their patient group. The neonatal HCPs explained that being exceptionally present and involved was required with newborns who were struggling. They underscored the elevated likelihood of losing a newborn in the neonatal department, posing a significant challenge if one is unprepared for such circumstances. In contrast, obstetric HCPs highlighted infant mortality is exceedingly rare in their department. They were concerned that confronting the death of a baby might be extraordinarily demanding, especially for those unaccustomed to working in a field where this is more prevalent.

The ethical dilemmas we’ll face will be different because you [obstetric nurses] will see the newborn’s suffering like we do, and we [neonatal nurses] will see the parents’ needs, dilemmas, and grief like you do—when they’re right next to each other, it’ll be different for all of us. (P14, nurse, neonatal)

HCPs suggested debriefing and defusing as tools to facilitate and process the various experiences involved in clinically and ethically challenging situations. One physician’s experience with defusing was that people involved more peripherally were often even more affected, an issue that could be important to be aware of when facilitating the debriefing. Being aware of the differences in HCPs’ perception of ethical challenges and building mutual understanding over time was called for. The participants suggested using workshops or dialogue meetings to discuss ethical dilemmas and clinical challenges across the two departments. HCPs believed that collaborating for couplet care could provide the opportunity to strengthen the experience of being united as a larger group and collectively coping with work-related challenges. They suggested that additional, mutual moral support could help alleviate the individual HCP’s burden.

It might be different if you’re not used to working in the intensive care environment … you mentioned a more direct tone [between HCPs] … but also, we face losing newborns … you must support the colleagues whose working environment will change. (P1, neonatologist)

The differing mindsets between intensive care and health-promoting settings are reflected in how HCPs communicate. For instance, HCPs noted that they use a more direct tone in acute situations in the intensive setting and being aware of this is essential to avoid misunderstandings and facilitate optimal mutual communication. This awareness is particularly important when working closely together as it can help prevent potential misunderstandings and miscommunications.

Subtheme 5: recognising educational requirements

I feel that it’s more about a general understanding of the mindset and workflow in the other department. To gain insight into ordinary everyday life, I don’t think that our skills should be the first thing to focus on. (P15, obstetrician)

To prepare for couplet care, HCPs raised the need for various educational initiatives. In general, many of them wanted an introduction to the other medical fields, for instance, by following a nurse or a physician in the obstetric or neonatal departments for a few days. They believed this would familiarise them with the working environment, foster collaboration and establish a foundation for team spirit across the departments. The HCPs felt that education focusing on common diagnoses, treatments and care for both mother and newborn would help prepare them before implementing couplet care. Their intention was not to make each other responsible for the treatment and care of each other’s patients but to gain a better understanding of what to expect, build confidence and clarify the responsibilities and expectations for each HCP in acute situations. The issue of acquiring skills in one another’s field posed a dilemma; they wanted to learn new skills but were insecure about the corresponding responsibilities. They suggested that workshops, online or simulation-based training or a combination of the two would be beneficial. They imagined that bedside learning would also be helpful during the implementation phase to take advantage of the learning environment that would arise in the room between the HCPs. To prepare and generate motivation for the intervention, they also suggested visiting a department with already functioning couplet care, especially for the team members who would be involved in implementing it.

Building bridges

The overarching theme encompasses the five underlying themes and serves as a metaphor for the HCPs’ desire to work more closely across the two departments while keeping newborns and mothers together. The five underlying themes help us understand that HCPs in the two departments currently operate on different platforms, not only in terms of physical location but also in terms of leadership, approach, culture and tasks associated with each department. A shared understanding of the family’s needs can unite them but organisational challenges must be addressed to facilitate collaboration between the two departments. There is no single solution for building the bridge that will successfully merge the specialities for the benefit of the family; it requires a multifaceted approach involving logistics, education, cultural and interprofessional dynamics.

Discussion

The present study of HCP expectations, concerns and educational needs related to couplet care identified one overarching theme, building bridges and five subthemes: Enhancing meaningfulness through increased teamwork, compromising or improving patient safety, challenging professional comfort zones, encountering other cultural and ethical values and recognising educational requirements.

During the focus groups, we realised that the interview process fostered a sense of support for the intervention that could promote greater unity between the two departments. We aimed to pave the way for enhanced collaboration by leveraging the dynamics within these focus groups as part of the pre-implementation process. The social interaction within focus groups is well studied48 and comparing experiences and perceptions produces new insights among participants. Bringing together HCPs from the obstetric and neonatal departments allowed for the exchange of perspectives on uniting families, revealing the potential for identifying common ground and in turn, facilitating more cohesive treatment and care across both departments. The overarching building bridges theme encompasses the idea that working collaboratively for a shared cause lays the groundwork for closer collaboration and keeping families together in the future. This insight could significantly influence HCP job satisfaction. It makes crucial awareness of the issue as it may be a key factor in the implementation process.32

HCP job satisfaction

Our findings showed that HCPs expected to enhance meaningfulness through increased teamwork. For the HCPs in our study, the value of implementing couplet care stems from the opportunity to improve the well-being of both mothers and newborns which could, in turn, positively influence HCP job satisfaction. This result suggests that management should prioritise closer collaboration between the departments early in the implementation process. Studies have shown that job satisfaction is an important predictor for avoiding burnout among HCPs but also indirectly affects patient satisfaction, quality of care and mortality.49 50 Furthermore, teamwork is essential for a safer and more effective healthcare system.51 52 Thus, supported by the increased teamwork between neonatal and obstetric departments arising from mother–newborn couplet care, greater meaningfulness in the job can lead to improved HCP job satisfaction and influence the quality of treatment and care. Our findings also showed that HCPs had concerns about the challenging professional comfort zones when working in a shared room. They needed clear role definitions and a plan for resource allocation. There is a difference between being knowledgeable about something and being responsible for it. Striking this balance is challenging and involves ensuring the staff feels secure. On one hand, staff may feel exposed if they are in the room without knowledge of the other patient. On the other hand, having knowledge can create a sense of obligation and staff may feel uneasy about being assigned responsibilities for which they do not feel adequately prepared. Maintaining a cohesive overall impression while balancing the need to respond professionally requires finding a way to be present in the room. It fosters a sense of security while projecting the appropriate level of professionalism suited to the atmosphere.

Taking into account the individual needs of both mothers and newborns

The results from this study showed how HCPs had concerns about compromising patient safety related to couplet care. Implementing couplet care poses challenges, particularly in addressing the diverse needs of mothers and newborns. Studies show that critical pregnancies or births impact both parents’ emotional and physical states, highlighting the need for individualised approaches to building parent–newborn connections.53–55 Some parents may struggle to bond with a critically ill newborn due to fear of loss.56 Often, the approach to the infant in these situations is ‘dosed’ at a pace where the mother can balance her physical and mental recovery while cautiously connecting with the newborn. When the mother and newborn are admitted separately, she has the opportunity to ‘self-dose’ their interaction which is not possible when they share a room. Therefore, HCPs in our study were concerned about how this would affect the mothers and how we could support any need for a gradual approach in other ways such as providing the mother with opportunities for rest and sleep. Sensitivity to each mother’s emotional state and personalised care can help bridge the gap between ideal couplet care and authentic experiences.19 Creating a calm, private, quiet and light-controlled environment for rest and sleep is essential57 58 though complex in shared rooms. At the same time, the newborn needs immediate and uninterrupted parental presence and closeness. Keeping the mother, newborn and the other parent in the same physical room might increase the possibility for parents to support each other. Supporting the importance of the other parent taking turns on skin-to-skin with the newborn to build closeness between the other parent and newborn might enable rest for the mother. Maintaining a balance between parent–newborn closeness and separation is an ongoing issue when addressing their needs and HCPs seek to achieve this in multiple ways in partnership with the parents.59

Supporting families individually necessitates a broad perspective

We found that the two departments had differences in cultural and ethical values. This information brings our attention to the importance of building a mutual understanding over time and the fact that this work could begin before the implementation of couplet care. For HCPs, a specific challenge when implementing couplet care is integrating the approach into the existing organisation which may require significant adjustments in workflow, resource allocation and coordination among the various departments.60 61 Overcoming logistical challenges necessitates collaboration, training and a commitment to prioritising the well-being of both mothers and newborns. While the challenges of implementing new interventions are well-recognised,62 there remains a limited understanding of the specific barriers, impacts and unintended consequences tied to the concept of couplet care. This lack of understanding is especially evident in highly specialised fields, highlighting the need for greater experiential knowledge. A recent study identified barriers that may encompass management priorities, financial constraints, spatial limitations and insufficient collaboration between units and clinical procedures.30 Striving to create a nuanced couplet care intervention, our approach included assessing the unique context within our departments and involving HCPs early in the development stage to fortify the implementation process.32 However, implementing couplet care cannot stand alone in supporting family formation. While enabling early connection and family formation is crucial, achieving this goes beyond simply implementing couplet care. Acknowledging the importance and impact of physical and emotional closeness, research indicates that other factors also have a profound effect on this delicate and individual process.63 One study found no discernible association between the duration of parent–newborn closeness in the neonatal unit and depressive symptoms in parents64 while another found this association.65 66 Another study found that introducing single-family rooms in the NICU increased parental presence but did not significantly alter the duration of skin-to-skin contact67 and others found an association between single-family rooms and skin-to-skin contact.68 Although parent–newborn physical closeness can enhance infant-centred and family-centred developmental care, skin-to-skin contact, early connection and family formation, supporting families individually necessitates a broader perspective.

Summary

This study highlighted the potential for stronger collaboration between obstetric and neonatal departments, fostering teamwork and improving care. While couplet care offers opportunities to enhance HCP job satisfaction, early connection and patient outcomes, concerns were raised about patient safety, role clarity and balancing the needs of both mothers and newborns. However, these concerns were expressed prior to the implementation of couplet care and may not arise in practice. The insights from this study are valuable as they reflect the challenges HCPs anticipate. Ensuring HCPs well-being, psychological safety and professional boundaries is essential for a successful implementation. A unique opportunity exists to strengthen collaboration between departments before relocating to the new children’s hospital. Pilot testing couplet care in the current setting can provide experience, allowing workflows and roles to be refined before scaling up.

Strengths and limitations

Comprised of participants from obstetric and neonatal departments, the four focus groups represented a combination of obstetricians, neonatologists, neonatal and obstetric nurses and one midwife enabling an interprofessional conversation. The social interaction within the focus group played a crucial role, contributing to the richness of data and aiding in the generation of knowledge about the complexity of meaning-making and social practices. The method provided a comprehensive understanding of potential departmental differences, providing valuable insights for the implementation process. The author group’s diverse professional backgrounds and experience enriched the analysis, enhancing their in-depth perspectives. Investigator triangulation added to the study’s credibility and our description of the participants and context increased transferability, while participant quotes improved dependability and our description of the sampling, data collection and analysis increased the study’s confirmability.43

The leaders of the two departments pointed out possible participants which strengthened the study by ensuring a high participation rate and management support. However, this may also be a limitation since the participants might have felt some pressure from management to participate. Since this study was conducted before couplet care was implemented, some HCPs found it hard to envision the process without concrete details, while others had no difficulty. A more specific scenario could have sharpened concerns but may have shifted focus to daily work routines which was not the aim of the study. Conversely, the hypothetical approach may have raised concerns that might not arise in practice. Including only one midwife was a limitation in our study; having a midwife in each group would have enriched the perspectives and provided a more comprehensive view.

Conclusions

HCPs widely support mother–newborn couplet care, emphasising the need for closer collaboration between neonatal and obstetric departments. Implementing couplet care is seen as meaningful, potentially enhancing the well-being of both mothers and newborns and positively impacting HCP job satisfaction. Key concerns include patient safety, quality of treatment and care and the well-being of HCPs navigating their skill level, psychological safety and professional boundaries. While the importance of couplet care for early emotional connection is acknowledged, challenges arise in meeting diverse maternal and neonatal needs. Additional research, especially in highly specialised care settings, is necessary to understand the complexities associated with changing the paradigm of care for newborns and mothers to be cared for together and in implementing couplet care. We found focus groups useful as a tool for uncovering and adapting practices to address challenges in implementing couplet care. Conducting the study again after implementation could provide valuable insights into which concerns were valid which turned out to be unfounded and which issues emerged that were not anticipated beforehand.