Abstract
Objective
The study explored parental views on their involvement in caring for their children admitted to the Neonatal Intensive Care Unit (NICU) at a hospital in Northern Ghana.
Methods
A qualitative descriptive exploratory design was used with 15 purposively sampled parents aged between 20 and 40 years. A semistructured interview guide was used to conduct the interviews with the participants. All interviews were audiotaped and transcribed verbatim. The data were analyzed using content analysis principles.
Results
Two themes were generated from the study. The first theme captured parents’ perception of their involvement in care, with the subthemes being parents’ understanding of involvement in the care of their children, parental involvement in the care of their children at the NICU, and their views on nurses’ attitude toward parental involvement in the care of their children. The second theme was the benefits of parental involvement in care at NICU, with the subthemes being parents’ benefits of their involvement in the care and parental views of nurses’ benefits of parental involvement in care at NICU.
Conclusion
Parents need to get involved in the care of their children admitted to the NICU. Nurses should teach parents some basic care activities during their children's admission. This will sharpen their skills to care for their children at home and increase their satisfaction with the services at the unit.
Introduction
Family Centered Care (FCC) is a concept that reflects a paradigm shift from considering patients and families as passive healthcare recipients to including them as active collaborators with mutual power-sharing (Kuo et al., 2012). The concept of FCC practices was designed for implementation in pediatric facilities of all kinds. The Neonatal Intensive Care Unit (NICU) is the ideal area for FCC to take place because of the unique and vulnerable nature of the mother/infant relationship (Feeley et al., 2020).
The involvement of parents in the care of their children admitted to the NICU is considered a global phenomenon that needs attention when practicing FCC. Parental involvement provides family strength and individualized care, as parents have the opportunity to learn basic nursing skills to care for their children at home (Prasopkittikun et al., 2020). Thus, parental involvement is a collaborative approach between parents and nurses in a well-designed healthcare delivery system.
However, nurses find it challenging to involve parents effectively and adequately in the care of neonates. For instance, a study conducted in Jordan's Hospitals to explore nurses’ perceptions of parental involvement in caring for their children in the neonatal unit found that nurses had a greater interest in caring for children alone than in parental involvement (Razeq et al., 2021). Also, other healthcare providers and hospital administrators expressed similar views regarding their experiences providing care for infants in NICUs with parent involvement (Benzies et al., 2019). A study has indicated that factors, namely nonavailability of time for nurses to be with parents, daily activities, child pain, affecting parents, and the risk of infection, limit nurses’ ability to guide parent involvement (Schmid et al., 2024). Despite the relevance of parental involvement in the care of their children and the associated challenges, rendering the involvement of parents in their children's care at the NICU difficult, there is still a need to allow parents to be involved in the care of their children. The study therefore sought to explore parental views on their involvement in caring for their children admitted to the NICU at a hospital in Northern Ghana.
Review of Literature
The essence of parental involvement in caring for their children admitted to the NICU is to enhance care outcomes, namely increasing the degree of family satisfaction, raising families’ awareness about the care, and establishing family and child strengths (Ding et al., 2019). For instance, Ding et al. reported that the outcomes for neonates whose mothers were involved in their children's care for four hours a day and were educated to perform activities such as hand hygiene, feeding, skin-to-skin contact, and infection control as well as basic care practices such as bowel care, bathing, and checking the baby's temperature were performing better as compared with mothers who were not involved in the care process (Ding et al., 2019). This implies that the involvement of parents in the care of their children in neonatal intensive care has a positive impact on parent–infant attachment, parent satisfaction, and infant weight gain, leading to the infant's faster recovery (Albayrak & Büyükgönenç, 2022). Also, parental involvement is known to improve family perception and practice toward health-related issues since there is a collaboration between nurses and parents during care (Shivalli et al., 2015) and increases the sense of parental responsibility for their children's health and a desire to be involved in the care (Roué et al., 2017). Besides, parental support during care in areas such as decision-making for their neonate is the most important area linked to the parental level of satisfaction (Hagen et al., 2019).
In the Ghanaian context, a study to explore the perceptions of nurses on FCC with parental involvement in the care of children hospitalized through road traffic accidents at the 37 Military Hospital revealed that most nurses perceived FCC to mean family involvement, although there was noninvolvement of parents in what was practiced (Ohene et al., 2020). The noninvolvement of parents was attributed to the fact that the concept of FCC was not a familiar phenomenon in the Ghanaian hospital setting. Thus, the principles, components, and dimensions appeared to be familiar in the Western context and alien to nurses in Ghana. For instance, a study conducted to examine the experiences and contextual practices of FCC from the perspectives of 42 families and 29 nurses in NICUs at the Tamale and Korle-Bu Teaching Hospitals in Ghana indicated that there should be a multidisciplinary approach to education involving parents to prioritize the provision of quality and satisfactory childcare regardless of the family's sociocultural background (Abukari et al., 2022). Based on these arguments, this study explores parental views on their involvement in caring for their children at the Intensive Care Unit in the hospital setting. Thus, the study explores parental understanding of their involvement in care, the benefits of parental involvement to the parents and nurses, and parental views of the nurses’ attitudes toward their involvement in caring for their children admitted to the NICU.
Methods
Study Design
An exploratory qualitative design was used to explore parents’ perceptions of their involvement in caring for their children during admission to the NICU. An exploratory descriptive design is valuable in understanding a phenomenon of interest (Polit & Beck, 2020). The design is used to explore the parental understanding of the involvement in caring for their children during admission at NICU, the benefits of parental involvement to the parents and nurses, and their views of the attitude of nurses toward their involvement in the care of their children admitted at NICU.
Study Setting
The research was carried out at a Hospital in Northern Ghana, a primary level facility in Northern Ghana, which serves as the metropolitan district hospital. The hospital serves as a referral center for clinics and nearby district hospitals in Northern Ghana. The NICU had a bed capacity of 50 (incubators—3, radiant heat warmers—6, baby cots—35, and beds—6) and a total staff strength of 36. The NICU has an average monthly admission of about 125. The unit is categorized as a level II (special care nursery) facility with incubators and continuous positive airway pressure devices to care for moderately ill or preterm babies born at 32 weeks or later.
Target Population
The target population was parents (mother/father) whose neonates were admitted and were being cared for at the NICU at a Hospital in Northern Ghana.
Sampling Technique and Sample Size
A purposive sampling technique was used to recruit the parents whose children were admitted to the NICU. Parents who were ill and not participating in the care of their baby in the NICU were excluded. Parents who could not communicate effectively in English were also excluded. The sample size was determined based on data saturation when there were no new data generated during the interview; thus, 15 participants were interviewed.
Data Collection Instrument
A semistructured interview guide was carefully designed based on the existing literature on the concept of family involvement and the study's objectives. The interview guide was divided into four sessions: Section A covered the study participants’ sociodemographic characteristics (Demographic data), Section B covered the study participants’ perceptions of FCC, with main questions including: What is your understanding of involvement in care? How are you (parents/caregivers) involved in the care of your baby here? Section C covered the benefits of parental involvement in care in NICU, with the main questions as: How will involvement in care benefit you and your child? How will your involvement benefit nurses? Section D covered the attitude of nurses toward parental involvement in care in NICU, with the main question being: What do you see as the nurse attitude and possible barriers to your involvement in care at NICU? The interview guide was pretested, resulting in the reframing of a few questions to ensure clarity and identification of possible probes. Face-to-face interviews were conducted with the participants to explore their views on their involvement in the care of their admitted children in the NICU.
Data Collection Procedure
The data collection procedure is a process of gathering and measuring information on participant variables of interest in an established systematic fashion that enables one to answer stated research questions (Jovancic, 2023). Permission was sought from the Hospital Director and the Nurse Manager through the Regional Health Directorate, with an introductory letter to gain access to the study area. Also, the nurse in charge of the unit (NICU) was informed to gain permission to conduct the study. Participants were recruited from April 3rd to 28th, 2023. Interviews were scheduled with participants and conducted within the same period in the unit charge nurse's office or in an available consulting room in the evenings when the unit is less busy. All interviews were conducted in English and were audio recorded with the agreement of the parents. The individual interview lasted between 30 and 45 min based on data saturation.
Data Analysis
The data collection and verbatim transcription were done concurrently to avoid losing relevant information. The data were analyzed using content analysis (Krippendorff, 2019). An inductive content analysis approach was used to analyze the data. This involves collecting and analyzing data without preconceived categories or theories. This allows the data to guide the researcher's analysis to identify emerging patterns, themes, and concepts (Delve & Limpaecher, 2023).
The transcripts were read several times by the researchers to become familiar with the data and to identify similar meanings in the data to form codes leading to themes and subthemes. The data were independently coded by the first and the second authors to arrive at robust themes and ensure that accurate assumptions were made from the interviews to develop the themes. These themes were reviewed to ensure there was a relationship between the themes and subthemes formed. This ensured that the formed themes reflected the meaning of the whole data. After this, the themes were defined and named to highlight their significance. Each theme was analyzed, along with the accompanying narration for the data. All discrepancies were discussed with the team to agree on the final themes and subthemes formed. Data analyses completed in June 2023.
Data Management
The data were managed by first saving the recorded interviews on a digital voice recorder. These recordings were later transferred to files on computers. The interviews were conducted in English. All transcripts were cross-checked (member checking) with participants to ensure their views were correctly captured. The data were examined and cross-checked for accuracy and coherent conveyance of the participant's narrative contribution.
Rigor
According to Guba and Lincoln (1989), to ensure the trustworthiness of a qualitative study, four types of standards are required, which are: confirmability, credibility, dependability, and transferability. The study incorporated strategies to establish credibility, dependability, confirmability, and transferability, as outlined by Korstjens and Moser (2018). Credibility was ensured through the use of member checking with the participants. Dependability was ensured through an external audit by the coauthors and the use of the same interview guide for all the participants and prolonged engagement with the participants to solicit their views on the topic. Transferability was ensured through the description of the research setting for easy replicability of the study in a similar setting. Confirmability was ensured by keeping a field diary of the research process for an audit trail.
Results
Demographic Characteristics of the Participants
A total of 15 parents were interviewed. The ages of the parents ranged from 20 to 40 years, with an average age range of 26 to 30 years. There was only one male parent (MP) and 14 females (FP). All the parents had some basic education and, therefore, could speak English. Six parents had attained tertiary education, five had completed senior high, three had attained junior high, and one had stopped in primary school. Five parents were employed (three teachers, one audit officer, and one nurse), six were traders and private business owners, and four were unemployed (housewives). All parents had only one child on admission (no twins). Seven parents’ babies were on admission for more than three days, while the remaining eight of the parents’ babies were on admission for 24–48 h. Table 1 below shows the demographic characteristics of the participants.
Themes and Subthemes
Parents’ Perception of Their Involvement in Care at NICU
Parents perceived their involvement in caring for their children in three ways: understanding the meaning of involvement in care, how they were involved in care at the NICU, and their views on nurses’ attitudes toward their involvement.
Two main themes were identified from the analysis of the data. The first theme captured parents’ perception of their involvement in care, with the subthemes being parents’ understanding of involvement in the care of their children, parental involvement in the care of their children at the NICU, and their views on nurses’ attitude toward parental involvement in the care of their children. The second theme was the benefits of parental involvement in care at NICU, with the subthemes being parents’ benefits of their involvement in the care and parental views of nurses’ benefits of parental involvement in care at NICU. Figure 1 below shows themes and their corresponding subthemes.
Parents’ Understanding of Their Involvement in the Care of Their Children
The parents explained their involvement as parents involved in caring for their sick babies, to know what is happening to their babies and to make decisions with the nurses. The involvement was also centered on information sharing, as recounted by some participants in statements below. “I think parental involvement is parents participating in caring for their sick babies during admission. This will allow you, the parent, to know what is happening to your sick baby and also make decisions with the nurse.” (MP1) “My understanding of parental involvement is that, let us say, when your relative is sick and he/she is being brought to the hospital and the doctors and the nurses share information with you on what you need to know about the condition of your relative.” (FP10)
Parents’ Involvement in the Care of Their Children in the NICU
The parents described ways or circumstances under which they felt they were involved in caring for their children at the NICU. Some parents mentioned that they were involved in caring for their babies during admission. According to them, nurses at the unit reassured and encouraged them (parents) to come in and breastfeed their babies or express breastmilk for them. The nurses also taught them (parents) how to feed and cuddle their babies when they are crying.
A participant narrated: “When my child was brought initially, he was on oxygen, so I was told not to breastfeed but to express breastmilk for my child. And they sometimes call me to come and observe how they feed the child. Sometimes, too, they call me in to come and see how my baby is doing. And the nurses sometimes encourage me not to worry, my baby will be fine.” (FP2) “A nurse called me to come and breastfeed my child when my baby was crying. And I sometimes express the breast milk into a cup so that they (nurses) can give it to the child later. And mostly when I am worried, they tell me my baby will be fine.” (FP10)
Another participant also stated: “The nurses call me when the child needs any drug or maybe the child is to go for any laboratory investigations, they give the blood sample to me to take it to the laboratory. And if they need cot sheets or dresses for the child, they also tell me to go and bring them.” (FP7) “The nurses educated me and called me to change my baby's diaper and clean my baby when necessary.” (FP6) “The nurse taught me how to breastfeed my baby, change her diaper, and clean her body every day in the morning and evening.” (FP10)
Nurses’ Attitude Toward Parental Involvement in the Care of Their Children at NICU
However, some parents indicated that some nurses’ attitudes during care at the NICU were not encouraging. Some parents stated that some nurses were not patient, making it difficult for them to be involved in caring for their children, and they were not given maximum involvement. “I think some nurses do not have enough patience for some of us, the parents. They want you, the parent, to do work fast and because we have not been practicing, it is difficult to do the work perfectly.” (FP13) “I must say that some of the nurses were not giving us maximum involvement in the care of our babies. We were only called to come when the baby was crying or when they needed something from us.” (FP14)
A participant stated: “I strongly believe language was a barrier. Because some of the nurses cannot speak my language and I cannot speak your language, it was difficult for us to communicate, thus affecting my (Parent) involvement in the care.” (FP1) “Luckily for me, I can speak English a bit, but some of the parents are Fulani and other tribes, so they cannot even communicate well with the nurses. Especially the Fulani people, the nurses do not understand their language and they also do not understand the nurses’ language. So, it is difficult to communicate, thus affecting their involvement.” (FP7)
Benefits of Parental Involvement in the Care of Their Children in the NICU
Parents described the benefits of their involvement in caring for their children in two ways: benefits to the parents and benefits to the nurses.
Parents’ Benefits of Their Involvement in Care in the NICU
Most of the parents stated that their involvement in the care of their sick babies benefits them in several ways, including increased affection between them (parent and child), leading to relief of their anxiety and fear, and clearing misconceptions about the NICU.
Some participants narrated: “Because I am allowed to breastfeed my child, it has increased the affection and relationship between us. It has also relieved me from the fear and anxiety that I will not be allowed to see my child. Moreover, as I am allowed to breastfeed, it has helped in the production of plenty of breast milk. I can see that my child's condition has improved. So, it is helping a lot.” (FP11) “As we are allowed to go in and see our babies, it has removed some fear in me as compared to a situation where I am lying somewhere and my child is also lying there, what if something happens to her? And as I am expressing the breast milk for her, I can see that the breast milk is coming because it was not coming when I was not expressing the breast milk. And I can see that my baby is improving.” (FP3)
A participant narrated, “ The truth must be told. When I informed some friends that my child had been brought here (NICU), they were like, if your child is brought here (NICU) and his /her condition is serious, you, the parent, will not be allowed to see your child. And if God does not intervene, you might even lose your child. So, I had that thought in mind, but when I got here, I realized it was not like that. I am no longer afraid because I am allowed to see my child. It has helped me a lot. When I come to breastfeed my child, I am always happy when I see her improvement. God bless nurses for implementing this practice.” (FP7) “The practice is good and helpful. Because I am allowed to learn a lot about some of the care I need to provide to my baby. I learned a lot, especially how to breastfeed my baby.” (FP10)
Parents’ Views on the Benefits of Their Involvement for the Nurses
Some parents mentioned that their participation in caring for their children at the NICU helped reduce the nurses’ workload as they (parents) helped feed the babies, change their diapers, and do other things to assist them.
A participant stated: “I believe that it would help reduce the workload of the nurses. Because you (nurses), your work is not easy. Sometimes I look at you and I say you are suffering. God bless nurses. If I come to feed my child and change his diaper, it will allow the nurses to also attend to other work. It will reduce the pressure on them.” (FP8) “ It reduces their (nurses) workload, maybe in changing of diapers, taking care of the baby, I even help in serving medication to my child.” (FP8)
A participant said: “If they involve parents in the care process of their babies, since we are with them (babies), we can provide some information to the nurses that will help in the care.” (FP9) “The nurses get information from us, for instance, if a baby is brought from the house, they could ask what was wrong with the child, so we (parents) would brief them about the incident that happened at home. So, they get information from us that will help in the care.” (FP7)
Discussion
The findings indicate that parental involvement was partly practiced at the NICU. Participants explained parental involvement as family involvement to provide support, namely giving medication, assisting with laboratory investigations, and other care activities during admission. This finding is similar to a study conducted in Southern Ghana at the 37 Military Hospital, where participants perceived that parental involvement in care means family involvement in the care process during admission (Ohene et al., 2020). The findings also explained parental involvement in the nursing care of their children to be limited to the involvement of the father and mother in the care, without considering other family members. Perhaps this could be attributed to a lack of space and personnel at the NICU in the facility that can fully engage families. Contrary to these findings, a study conducted in Norway showed that the involvement of extended family members in care in NICU settings led to better health outcomes for preterm infants (Hagen et al., 2019). This shows that to develop collaborative relationships with families of sick children in the NICU and make decisions about the care procedures, health professionals, managers, and institutions must create the necessary avenues and train nurses on parental involvement in the care process.
Additionally, evidence from the study interview showed that nurses involved parents in the care of newborns at the NICU. However, nurses determined the needs of the parents and planned their children's care without collaborating with the parents. The results were in line with the outcome of a study conducted in Turkey, which revealed that the decision to allow parental involvement in their children's care is based on the unit's needs, with support from managers (Albayrak & Büyükgönenç, 2022). In the current study, nurses encouraged mothers to frequently come and see their children to relieve their anxiety and fear. This allows parents to also get to know whether their children's condition is improving or not. This supports a study that indicated that most parents reported moderate to high satisfaction with care because they were encouraged to spend more time with their infants and participate in their care (Hagen et al., 2019).
The current study found that involving parents in the care appears to improve the working capacity of the nurses, as parents run errands and breastfeed babies. Similarly, a study indicated that parental involvement in their children's care improves the working environment of nurses at the NICU (Hallowell et al., 2019). Moreover, in the current study, it was further noted that parental involvement during care at the NICU increased the bond between parent and baby, allayed their anxiety and fears, and prevented parental neglect of the baby while they were on admission. As a result, babies’ needs are immediately provided for since parents are involved in nursing babies on admission. In a related study, nurses reported that parents who were depressed and anxious when their babies were brought into the NICU because of their health conditions developed increasing love for their babies and involved themselves in the care of these babies (Prasopkittikun et al., 2020; Roué et al., 2017).
However, the study revealed that some nurses’ attitudes affected parents’ involvement in caring for their children. Some nurses did not involve the parents, while some were not happy with parental involvement, stressing that it affected their work. In support of this, a previous study reported that nurses’ attitude toward parental involvement was affected by their own evidence-based practice and knowledge awareness (Albayrak et al., 2023).
Also, the study found that if parents were involved in caring for their babies, the rate of infection and its associated complications would drastically reduce since they would have acquired some skills in personal hygiene and managing babies’ conditions while at home. In a comparative study, parents involved in nursing their babies during admission at the NICU received education on infant development, hand hygiene, feeding methods, skin-to-skin contact, infection control, and some basic care practices such as changing, bathing, and taking the baby's temperature. These mothers’ babies developed fewer complications compared to mothers who were never involved in caring for their babies on admission (Ding et al., 2019).
Implications for Nursing
The study findings imply that nurses need to involve parents in the care of their neonate in the NICU to enable them to acquire the requisite basic skills that will assist them in caring for their children at home. There is also a need to establish effective communication with the parents to enhance their education.
Furthermore, the findings indicate that successful healthcare experiences and positive long-term outcomes are driven by good communication and relationship building, the importance of validating parents’ concerns by listening to and involving them in decision-making, Also, interventions supporting parental decision-making and management could help to alleviate current health service workload, Therefore, building and maintaining trust and positive relationships between parents and nurses should be a priority.
Strengths and Limitations of the Study
Family-centered care is a fundamental concept in the care of children; however, its implementation in complex healthcare settings could be challenging. This study has espoused parents’ subjective understanding and conceptualization of how they were involved in the care of their babies in a complex healthcare environment like the NICU, as well as some notable areas for improvement. However, the researchers acknowledge that generalization of the findings beyond the context of the study could be limited by a purposively selected and relatively few samples. Also, conducting the interviews in the English language only further limited the possibility for diversity. Prolonged engagement and adequate probing ensured that sufficient data were generated to address research questions. Also, there is a possibility of social desirability bias, as respondents may have given answers they believed presented themselves in socially acceptable terms. Participants were constantly assured of confidentiality and encouraged to freely share their perspectives. Future research could integrate the views of both nurses and patients using focused group interviews to give a comprehensive outlook on parental involvement.
Conclusion
The study explored parental involvement in caring for their children at the NICU in a hospital in Northern Ghana. The findings showed that parents have different understandings of their involvement in care for their children. Involving parents in caring for their children also has certain benefits to both the nurses and the parents. Parents get the opportunity to learn basic caring skills that will help them care for their children at home. Thus, the findings imply that involving parents in caring for their children in the NICU is beneficial to their children's health outcomes.
Themes and subthemes.
Demographic Information.
FP = female parent; MP = male parent; SHS = senior high school; JHS = junior high school; CHD = congenital heart defect.
Supplemental Material
sj-docx-1-son-10.1177_23779608261430479 - Supplemental material for Parents’ Perceptions of Their Involvement in Their Babies’ Care in the Neonatal Intensive Care Unit: A Qualitative Study in Northern Ghana
Supplemental material, sj-docx-1-son-10.1177_23779608261430479 for Parents’ Perceptions of Their Involvement in Their Babies’ Care in the Neonatal Intensive Care Unit: A Qualitative Study in Northern Ghana by Bernard Atinyagrika Adugbire, Millicent Aarah-Bapuah, Lilian Serwaa Antwi, Gifty Appiah and Ayishetu Haruna Kombert in SAGE Open Nursing
Footnotes
Acknowledgments
The authors acknowledge the participants for their participation in the study. The authors also acknowledge the hospital management for granting permission to conduct the study at their hospital.
Ethic Approval and Consent to Participate
Ethical clearance was REDACTED. An introductory letter to the Medical Director and Director of Nursing Services of the Tamale West Hospital was obtained from the Head of the Department of Paediatric Nursing. The hospital management granted permission to the authors for the study to be conducted. Before conducting the individual interviews, informed consent was sought in written form from all the participants who were involved in this study, and they were assured that their participation was voluntary and they could opt out when deemed necessary. The purpose, risks, and potential benefits of the study and publication were explained to the participants. The participants’ anonymity and confidentiality were guaranteed with the use pseudonyms (FP, MP).
Consent for Publication
Consent for publication was sought from the participants and this was approved.
Author's Contributions
Bernard Atinyagrika Adugbire conceptualize the idea of the manuscript and drafted the manuscript. Bernard Atinyagrika Adugbire also review and edited the manuscript. Millicent Aarah-Bapuah involved read the manuscript, development of the themes and subthemes in a figure form, reviewed and edited the manuscript to ensure it met the journal standard for publication. Lilian Serwaa Antwi collected the data using the interview guide and also participated in the data analyses. Gifty Appiah transcribed the data from audio to text and reviewed the text to ensure information conformed the views of the participants and Ayishetu Haruna Kombert analyzed the data the transcribed data. They were involved in the writing and reviewing of the manuscript.
Availability of Data Materials
The data and materials are available with the corresponding author and may not be made available due the sensitive nature of the participant's responses.
Study Approval Number
This was not applicable due the granted permission from the hospital management upon the receipt of an introductory letter from the authors.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The manuscript was funded by the authors self-funded, (grant number none).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Supplemental Material
Supplemental material for this article is available online.
References
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