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When premature and ill infants are admitted to a neonatal intensive care unit (NICU), parents are often stressed, and their mental health might be affected.1,2 The infant's unexpected hospitalization, the NICU physical environment, alarms from equipment attached to their own infant or other infants, and the uncertainty about their infant's chance of survival are all stressing factors.3 Parents' psychological well-being is essential for the ability to establish a parent–infant relationship, which is important for the infant's social and intellectual development. Likewise, the relationship enhances parents' confidence and capabilities in providing care for their infants.2,4–6
Fathers are often expected to take care of and protect both the infant and the mother, but they also need to be supported and encouraged to share their worries and stress.7–9 Even though fathers indicate that nurses are a source of support during their infants' hospitalization,10 their needs for information, support, and guidance are generally not met,3,7,8,10–18 which can partly be attributed to the fact that mothers traditionally have been the focus of the nursing staff.7,12,16 Likewise, studies18,19 have found that nurses lack recognition of fathers' needs and that their experience of giving support to them is not satisfactory.
The role of fathers in the NICU has been changing recently, with many fathers insisting on being present and active participants in childcare on an equal footing with mothers.14,15,20,21 Ensuring fathers' ability to participate in care is a prerequisite for delivery of family-centered care, which several authors have recommended for implementation in NICUs.22,23 Family-centered care refers to a form of care that is planned around the whole family and not only the patient.24 Therefore, the involvement of the staff in supporting both parents is essential to manage and reduce their stress and thereby increase their parenting role.1,3,16,25,26
To meet these requirements, we first investigated the needs of fathers in our NICU. We found that fathers had a desire to be involved and to be active fathers to their infants. They needed to receive direct information and guidance from the staff and to have an opportunity to talk freely about their feelings and ask questions without paying attention to their partner.8 Based on these findings, we implemented in cooperation with the staff and management the principles of a father-friendly NICU (FF-NICU) to meet the needs of both fathers and mothers at the NICU at the University Hospital of Southern Denmark, Kolding27 (more details regarding the FF-NICU are provided later in the article).
In the father-friendly NICU, it was essential that nurses had a mindset that indicated that fathers were as important a parent as mothers. Likewise, they should feel safe and competent in supporting and cooperating with fathers. Only a few intervention studies have focused on evaluating the competencies of the staff to carry out specific tasks, to cope with new methods and approaches, etc. Self-efficacy (SE) is a person's belief in his own ability to succeed in a particular situation, and these beliefs determine how people think, behave, and feel.28 The higher the SE, the better their experience of being confident in supporting and guiding fathers. Therefore, this study aimed to investigate the nursing staff's evaluation of their own SE of guiding and supporting fathers after the implementation of the FF-NICU.
What This Study Adds By implementing a father-friendly NICU, nurses' SE for providing support to fathers increases significantly. Through education and training in a father-friendly approach, nurses' ability to support both parents in different situations increases and thus creates a greater awareness of involving the whole family. Continue having focus on fathers' needs and their wish to be considered as equally important parents as the mother. METHODS DesignThis quantitative study using questionnaires in a pretest/posttest design was a part of the intervention project titled “What Effect Does a Father-Friendly NICU Have on Children, Parents, and Staff?” conducted at the Department of Paediatrics and Adolescent Medicine at the University Hospital of Southern Denmark, Kolding.8,11,27
SettingThe study was conducted at a 22-bed level II/III NICU that yearly treated approximately 600 critically ill infants and premature infants with a gestation age of 28 weeks or more independent of weight. Mechanical ventilation was only used to stabilize infants in need of being transferred.29 The presence of parents and siblings was unrestricted. All families had an armchair next to the infant's incubator or cradle at their disposal, and parents slept in a patient hotel adjacent to the NICU. Fathers had to pay for staying at the hotel. One week before discharge, parents could room-in with their newborn infant in a family room in the unit without being charged. Thirty-eight nurses, 2 assistant nurses, and 4 medical doctors worked in the unit.
Intervention DevelopmentThe FF-NICU was developed from August 2011 to January 2013 using participatory action research involving fathers, mothers, interdisciplinary healthcare professionals, and managers to develop a NICU that met the needs of both fathers and mothers. Methods used were participant observation, semistructured interviews, multisequential interviews, workshops, focus groups, and group discussions. Data were analyzed following grounded theory as defined by Charmaz.30 The analyses found that nurses rarely paid attention to fathers and their worries. At admission, fathers were worried about both the infant and the partner and wanted to talk to other fathers in the same situation. Fathers expressed a need to be in control and therefore asked to be directly informed of their infant's progress. Furthermore, they wanted to be engaged in childcare but were balancing between being at the hospital with the infant and partner, being at work, or being at home caring for older siblings. Data analyses and findings were presented and discussed at a seminar involving all interdisciplinary staff members and the management of the NICU. Based on this seminar, all stakeholders were involved in the development of and decision-making process to implement a father-friendly approach, where fathers were considered as equally important parents as the mother. To achieve this, 8 concrete initiatives were developed to meet the identified needs and wishes (see Supplemental Box 1, available at: https://links.lww.com/ANC/A216).8,27
ImplementationThroughout the implementation period, which was initiated in February 2013, different activities were conducted at the NICU to engage and educate the staff members and adjust the concept. A senior nurse with a pedagogical education carried out bedside practice for 1 day with each of the nurses to reflect and support the nurse to better collaborate, guide, and support parents in a professional way. Discussions and reflections related to principles of the FF-NICU were held at the daily nursing conferences. Furthermore, 14 nurses with different seniority participated in 3 different focus groups. Each group met 3 times during the implementation process. For these 9 group sessions, the aim was for the staff to reflect on their own experiences before and after the implementation of the FF-NICU. The participating nurses shared the discussions and reflections with their colleagues in the NICU so that all the nurses could improve their support and guidance of fathers in daily practice. Furthermore, the researcher (first author) was present every weekday and was in an ongoing dialogue with the staff about their successes and problems in their interaction with fathers and the father-friendly initiatives.
EvaluationThe intervention was fully implemented by August 2013. A before-and-after evaluation was performed to investigate the impact of the FF-NICU on fathers' stress and their participation in childcare using the Parental Stressor Scale: Neonatal Intensive Care Unit. We found that after the implementation of the FF-NICU, fathers were more stressed, which might be due to a higher expectation of being present and taking part in childcare.11 A before-and-after study found that parents reported a high level of staff support in both pre- and postintervention.31
The present study evaluates the impact of the FF-NICU on nurses' SE of guiding and supporting fathers after the implementation of the intervention.
SampleOf the total 17 other Danish NICUs, 13 agreed to participate in this study (control group). All nurses from these 13 NICUs and from the study NICU (intervention group) were invited to participate in the study. Nurses without patient contact or on maternity or long-term sick leave were excluded.
InstrumentsMotivated by a pilot study at the intervention NICU32 regarding nurses' subjective evaluation of their own care of parents, we designed a questionnaire intended to measure SE. This process was also inspired by the validated questionnaire The Nurse Parent Support Tool,33 which targeted parents to assess how they felt nurses' care had supported them.
The questionnaire contained 3 sociodemographic items and 14 questions related to the father and the same 14 questions related to the mother, in which nurses were asked to evaluate their own ability to guide and support parents in different situations (SE score) in general and not in relation to a specific mother/father or in relation to specific work situations (eg, busyness in the department). For each of the father and mother questions, nurses were asked to rate themselves on the following statement: “How confident are you that you can perform successfully ...” using a scale from 1 to 10, where 1 indicated “not at all sure” and 10 indicated “quite sure.” From these answers, the total SE score was calculated. Questionnaire items are presented in Supplemental Box 2 (available at: https://links.lww.com/ANC/A217).
The content validity of the questionnaire was tested by 8 nurses in 2 NICUs. The validity was tested for consistency, clarity, and relevance.34 The questionnaire was adjusted for minor linguistic changes in accordance with their answers.
ProceduresPreintervention SE scores were obtained just before the initiation of the development of the FF-NICU in August 2011 (QI). To determine whether the development process influenced nurses' SE, we made a second preintervention measurement just before implementing the intervention in January 2013 (QII). To evaluate how the new concept had changed the clinical practice, a third questionnaire was completed in January 2015, 18 months after the implementation (QIII). Stages of the study are presented in Figure 1.
FIGURE 1: Study timeline.
Before each questionnaire, head nurses from the participating NICUs prepared a list of nurses who were eligible for inclusion. Nurses were asked to answer the questionnaires at QII and/or QIII even though they were newly employed, had been on maternity or long-term sick leave, or had not responded to the previous questionnaires. The questionnaires were administered using SurveyXact (http://www.surveyxact.com/). The included nurses were given an Id code, so combining data for the 3 questionnaires and sending reminders were possible. If they had not answered within 1 month, a reminder was sent, and again a reminder was sent 14 days later if they had not answered.
EthicsThe study was approved by the Danish Data Protection Agency (No. 19/20297). In accordance with Danish law, this study did not need to be reviewed by an ethics committee. Nurses were informed about the study in writing and, if they wished, orally before they agreed to participate. Participation was voluntary, and nurses could withdraw at any time. For all questionnaires, only the researcher knew the coding, and confidentiality and anonymity were guaranteed. The procedures were in accordance with the Helsinki Declaration.
OutcomesThe primary outcome was the difference between nurses' SE scores for father and mother questions from QI till QIII in the intervention group compared with the control group.
Secondary outcomes were (1) the difference in nurses' SE scores on father questions from QI to QIII in the intervention group compared with the control group; (2) the difference in nurses' SE scores on father questions in the intervention group compared with the control group from QI to QII; and (3) the difference in SE scores on father questions in nurses with low and high seniority in the intervention group compared with the control group from QI to QIII.
Statistical AnalysesFor each questionnaire, nurses' SE scores on mother and father questions were calculated by adding up the scores and dividing them by the number of questions. Differences in SE scores were tested using the Mann-Whitney test for unpaired data and the Wilcoxon signed-rank test for paired data.
We chose to report data based solely on nurses' seniority because we believed that age and seniority are closely linked and that seniority could be a factor in a person's SE. We dichotomized nurses' seniority into 2 groups: nurses with low (<6 years) and high (≥6 years) seniority.
Data were analyzed using Stata statistical software (Release 16; Stata Corp, Texas).
RESULTS ParticipantsNICUs in the control group represented both regional and university hospitals. One unit was a level II, 10 level II/III, and 2 level III NICUs.29 In the intervention group, 38 (100%) nurses answered the questionnaire at QI, 38 (100%) answered at QII, and 38 (97%) answered at QIII; the corresponding numbers for the control group were 256 (56%), 292 (65%), and 250 (60%), respectively (Table 1).
TABLE 1. - Number of Nurses Answering Different Questionnaires in the Intervention Group and Control Group Questionnaire at Intervention Group Control Group QI QII QIII QI QII QIII Included 38 38 39 458 452 419 Not responding 0 0 1 202 160 169 Responses received 38 38 38 256 292 250 Answered both at QI and at QII 34 166 Answered both at QI and at QIII 31 123 Answered both at QII and at QIII 33 169It was possible to match 34 and 166 nurses from the intervention and control groups, respectively, who responded to both questionnaires at QI and QII. Thirty-one and 123 nurses from the intervention and control groups, respectively, responded to both questionnaires at QI and QIII. Thirty-three and 169 nurses from the intervention and control groups, respectively, responded to both questionnaires at QII and QIII (Table 1).
Comparing the seniority of nurses in 2 groups showed no differences in any of the 3 questionnaire assessments. Significant differences were found in comparing the seniority of nurses answering both the questionnaires at QI and QIII and at QII and QIII in both groups and for the control group at QI and QII. In the intervention group, nurses were significantly older at QIII than at QI and QII (Table 2).
TABLE 2. - Characteristics of Participating Nurses Questionnaire at Intervention Group Control Group QIaAge and seniority are missing for 3 and 2 participants, respectively.
bAge and seniority are missing for 4 participants.
cAge and seniority are missing for 5 participants.
In the intervention group, a significant increase in SE scores for questions from QI to QIII was found for 8 out of 14 (57%) and 2 out of 14 (14%) questions for father and mother questions, respectively. The corresponding results for the control group were 7 out of 14 (50%) and 3 out of 14 (21%). No changes in SE scores were found for any of the remaining questions in any of the groups (see Supplemental Table 1, available at: https://links.lww.com/ANC/A218, and Supplemental Table 2, available at: https://links.lww.com/ANC/A219).
When comparing the difference in SE score for questions at QIII between the intervention and control groups after implementing the FF-NICU, significant differences were found in 12 out of 14 (86%) and 2 out of 14 (14%) for father and mother questions, respectively (see Supplemental Table 1, available at: https://links.lww.com/ANC/A218, and Supplemental Table 2, available at: https://links.lww.com/ANC/A219).
From QI to QII, a small increase was observed in nurses' mean SE scores for father and mother questions in both groups. In the control group, the increase was significant regarding father questions (Table 3).
TABLE 3. - Nurses' Evaluation of Self-Efficacy Regarding Father and Mother Questions in the Intervention Group and Control Groupa Questionnaire at Intervention Group Control Group Intervention vs Control Group QIAbbreviation: SE, self-efficacy.
aThe Mann-Whitney test was used. P values italicized are significant.
bDifference between mean SE scores in questionnaires at QIII and QI in the intervention and control groups, respectively.
In both groups, significant increases in mean SE scores from QI to QIII for father questions and for the control group, also for mother questions, were found (Table 3).
The same results were found when including only nurses who had answered the questionnaires at both QI and QIII. Moreover, the increase in mean SE scores for mother questions reached statistical significance in both groups (Table 4).
TABLE 4. - Self-Efficacy for Nurses Who Responded to Both the First and Third Questionnaires in the Intervention Group and Control Groupa Questionnaire at Intervention Group Control Group Intervention vs Control Group QIAbbreviation: SE, self-efficacy.
aP values italicized are significant
bThe Wilcoxon signed-rank test was used.
cThe Mann-Whitney test was used.
dDifference between mean SE scores in questionnaires at QIII and QI in the intervention and control groups, respectively.
In the questionnaire at QIII, answered after implementing the FF-NICU, the intervention group showed a significantly higher mean SE score for father questions compared with the control group (Table 3). The difference remained significant when the analysis was limited to nurses who answered the questionnaire at QI and QIII (Table 4).
Comparing the differences between mean SE scores for mother and father questions, significant differences were only seen when comparing the answers at QI with those at QII and the answers at QI with those at QIII for the control group. The difference between nurses' mean SE scores for fathers and mothers remained unchanged. In the intervention group, a significantly greater reduction in the size of the difference in mean SE scores from QI to QIII was seen compared with the control group both with respect to the difference in father questions and the difference between mother and father questions (Table 3). A significant difference persisted in an analysis limited to nurses who had answered the questionnaires both at QI and QIII (Table 4).
In both study groups, nurses with high seniority had significantly higher mean SE scores compared with nurses with low seniority both for father and mother questions at QI, whereas a significant difference at QIII was only observed in the control group (Table 5). Nurses with high seniority from the intervention group had a significantly higher mean SE score at QI for both father and mother questions and at QIII for father questions compared with nurses from the control group (Table 5).
TABLE 5. - Nurses' Evaluation of Self-Efficacy by Senioritya Questionnaire at Intervention Group Control Group Intervention Group vs Control Group QIaIn the control group, 2 and 5 nurses did not answer the question on seniority in the first and third questionnaires, respectively. P values italicized are significant.
bThe Mann-Whitney test was used.
The changing role of fathers in parenting,8,20,21 and their experience of not being involved, informed, and guided in their infants' care as equal parents, requires that nurses' competencies should be adapted to the need for care and guidance of the whole family.
Our study found an overall significant increase in SE when nurses in the intervention group evaluated their own capability to guide and support fathers from before till after the implementation of an FF-NICU. Since these changes could have been due to other measures, changes in SE were compared with those observed in other Danish NICUs that did not introduce a father-friendly approach, in which a minor but also significant increase was found. The fac
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