Listening to families and staff

Active listening has been the most powerful element in our model of FIC. We learnt to put aside assumptions and hear the views of families and staff.24 This was critically important to understand the practical needs of families, to create new collaboration between staff and families and to engage all staff giving them a voice in shaping our work.

We use monthly ‘HUGG meetings’ to listen to staff and parents. These informal, non-hierarchical meetings are open to families, past and present, and all staff in the Unit, who come together to share experiences and develop ideas. They have had a profound effect. Families feel valued and part of our team. Staff heard directly how it feels to be a parent in the Unit, and are motivated by this. For any team embarking on FIC, we recommend taking the time to regularly sit down with families and hear their voice.

We also created surveys, in electronic and paper format, to listen to those staff and families who were unable to attend meetings. By gathering everyone’s opinions, we formed a consensus model of FIC and hoped to reassure staff that change was guided by them.

Empowerment

Empowering staff was the next step in our model of FIC. They create the environment and relationships to support families as carers. Many of our ‘early adopters’ were staff nurses, who were willing to challenge current practice to improve care. HUGG allowed them to develop as leaders by bringing them together, inspiring them with visits to other FIC centres, listening to their ideas and giving them permission and support to work across traditional groups and hierarchies.

Not all staff were ready to embrace FIC at first. Some worried that FIC would be imposed without consultation, that parents would be trained to perform complex care (such as blood-taking or endotracheal suction), or that it was a strategy to reduce nursing numbers. We learnt to slow our pace, listen to everyone’s views and took every opportunity to have informal, honest discussion with colleagues about FIC. We used ‘myths and truths of FIC’ posters to dispel misconceptions. We also shared powerful positive feedback from families, in our meetings, newsletters and information videos sent by email to all staff. Opinions began to change as staff saw the benefits for families, and also for themselves as part of more cohesive, social and happier team.25 For those staff with ongoing concerns, a simple but important question often helped: what would you want if you were a parent in the neonatal unit?

Empowering families is also key to FIC, both as primary caregivers for their baby and as team members working with staff to design and implement our model of FIC.26 The simple process of listening to parents, at HUGG meetings in particular, gave them power to shape our model. They helped us develop a practical framework and innovative ideas to empower all families as primary caregivers.

Communication

To improve communication, we introduced simple shared whiteboards at each cot space for families and staff to leave messages. This ‘frugal innovation’ had a profound effect, creating a new connection, and as one family put it ‘a voice for our baby’.28

Another idea came from a father who asked if we could send short videos of his son when he could not be in the neonatal unit. We worked with a commercial provider, and local governance team to develop and pilot a system for families (www.vcreate.tv/secure-video-messaging). Staff create short messages, often overnight, and send these securely to parents. Receiving a video message reassures families and helps form a connection with staff. Mothers report that receiving videos of their baby reduced their anxiety, helped them express breast milk and sleep.

Parent education

Parent education is central to FIC. To empower parents with the skills and knowledge to be primary carers, we organise daily family awareness sessions (figure 1). Topics are suggested by parents and sessions are led by nurses, nursing assistants, physiotherapists, pharmacists, dieticians, psychologists, neonatologists and ‘graduate’ parents. Sessions are informal with time for questions and discussion. All parents and family members are welcome to attend, to learn new skills and support each other.29

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Figure 1

Family awareness sessions, example of monthly calendar. Sessions are suggested by parents and led by staff, bringing parents together to learn, share and support each other. NICU, neonatal intensive care unit. Source: Images are owned by Helping Us Grow Group (HUGG), Royal Hospital for Children, Glasgow. (Permission for publication is granted on behalf of HUGG).

Parent feedback from initial sessions was excellent, however attendance was variable. Families told us that they often forgot to attend. Our solution was to send parents an automated text message reminder (www.getflorence.co.uk) before each session and follow-up texts with links to relevant online resources including breast feeding support and resuscitation training.30

Peer-to-peer support

Enabling parents to meet, share experiences and support each other is an important component of our FIC programme.31 Many families have developed strong and lasting connections after meeting regularly at our family awareness sessions. One mother told us that these sessions were the ‘only sane hour of her day’.

We also organise an annual reunion party for ‘graduate’ families. These maintain ongoing relationships, celebrate the progress of former patients and are an opportunity to gather parents’ views and engage them as ‘veteran parents’.

Staff education

From the outset, staff told us they needed education and support to provide FIC. However, in view of initial resistance to FIC, we elected to take a gradual, stepwise approach, rather than imposing a broad training package. We started by focusing on the one element of care that 100% of staff agreed parents should perform KMC. We were surprised how quickly attitudes and practice changed. Initially, only 33% of staff reported feeling confident to support KMC. One month later, 75% of families were performing KMC, supported by staff. No significant intervention had been made in the meantime. We believe that simply asking the question ‘nudged’ staff to reflect and change their own practice.32 To test our theory, we asked if it was possible for all families to hold their baby. We set this friendly challenge on Christmas Day and were delighted when staff proved it could be done, and even created a video of the day to share with their colleagues.

Resources and environment

We wanted to create an environment where families feel at home, to encourage them to be present and involved. Parents told us they became anxious and frustrated waiting at the security door. We installed a biometric (fingerprint) scanner so parents could let themselves in, reinforcing the message that parents are not visitors.

We also engaged parents in the design of resources in the Unit. They chose our name and logo, and designed cot-side family update charts (figure 2). These charts are completed daily by parents and act as highly visual prompts for staff. They are simple but effective, empowering parents to indicate which care they want to provide for their baby and request training when they are ready.

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Figure 2

Family update chart. A concept and design by parents to support family involvement in every baby’s care. Source: Images are owned by Helping Us Grow Group (HUGG), Royal Hospital for Children, Glasgow. (Permission for publication is granted on behalf of HUGG.)

As staff acceptance of FIC increased, we felt ready to address more thorny issues including developing our policy of unrestricted 24/7 parental presence. Nursing handover was a particularly divisive issue, 21% of staff felt parents should never be present, 19% felt they should always be present during handover. Again, listening was key to addressing this impasse. We surveyed all nursing staff and used their ideas to create a new policy that supports parents to be present but includes procedures to ensure safe handover of confidential information.

Similarly, we grappled with parent involvement on ward rounds. We wanted to support their active participation but worried about confidentiality. Staff could not agree, but parents gave us a workable solution. The majority told us that they did not mind other families being present, had no interest in eavesdropping and understood if they were asked to step out. They favoured a flexible, pragmatic policy and trusted staff to manage this.