Nurses play a critical role in the integration of quality improvement initiatives to progress and promote effective care within the healthcare setting. Nurses must use leadership and management strategies to address areas in need of improvement and change. Nurses have a duty to identify when there is opportunity to advance and reconstruct the quality of healthcare for the better (Huber, 2018, p. 268). For instance, a problem in paternal bonding within the neonatal intensive care unit (NICU) would call for an opportunity for nurses to fix and respond to the problem. With this responsibility nurses in management and leadership positions must be willing to educate, inform, and keep up with current medical research and evidenced-based practices, while encouraging and teaching other nurses to do the same (Huber, 2018, p. 298). Nurses continually have the opportunity to be crucial part of change for the healthcare system.
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The problem in the NICU setting is that fathers are not bonding with their infant due to a lack of education and enforcement of bonding practices by nursing staff. This issue will be addressed by the Quality and Safety Education for Nurses (QSEN) in the topic of quality improvement. Quality improvement is defined as the use of, “data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems” (Quality and Safety Education for Nurses [QSEN], 2019). This problem fits into the QSEN topic of quality improvement because there is a need for enhancement and enforcement of techniques to encourage and guide paternal bonding in the NICU setting. Specific interventions and outcomes should be used and monitored to see which method is the most effective to fix this issue. Since there is not a present protocol on paternal bonding within the NICU, the use of data from paternal experience within the NICU would be beneficial step towards solving the problem.
Assessment and Analysis
The problem of paternal and infant bonding in the NICU was identified through reviewing current research and scholarly journal articles. This problem involves fathers, infants, and nursing staff. A study observing paternal bonding conducted in the NICU setting found that many fathers felt like an “outsider” to the mother and nurses and did not participate in care as much as they would have liked to during their infant’s stay (Logan & Dormire, 2018). Fisher et al. (2018) states that engagement of fathers in the NICU has been immensely disregarded in healthcare facilities resulting in fathers having feelings of “powerlessness” and “exclusion.” Many parents may also have a hard time bonding with their infant because of restrictions within the NICU due to their infant’s medical condition, stress from having a sick infant in the hospital, and financial strain. Fathers, may specifically feel left out with the immense amount of focus on the mother.
Currently there are no policies or procedures that directly focus on how to increase paternal bonding in the NICU, but there are suggestions and evidence-based practices to facilitate parental and infant bonding during the NICU period. Some practices within the NICU include: skin to skin contact (SSC), involvement in care, and frequent visitation (Feeley, Genest, Niela-Vilen, Charbonneau, & Axelin, 2016). Although there is currently not a problem with these practices, the lack of enforcement and education of it regarding the benefits of these practices, or how often they are practiced is a problem, especially concerning fathers. Hence, more education and enforcement of these practices should be offered to fathers by nursing staff in the NICU setting.
Based on the evidence, the direct inclusion of fathers should be encouraged through education and nursing practices. With this proposed change nurses will be able to inform, educate, and encourage fathers to be active participants during their infant’s stay. Education about paternal and infant bonding among the nurses, physicians, and healthcare staff should be implemented on the unit. This change could help adverse events such as impaired paternal and infant bonds from forming combating future attachment issues. Much of the care is focused on the maternal bond, rather than the paternal bond. Evaluating needs of both parents individually should be a priority for each NICU experience. Fathers, if willing and abiding by the procedures or practices of the unit, should feel competent and confident when practicing bonding techniques with their infant with the help of nursing staff.
Research on the topic of paternal bonding in the NICU was found through the use of databases such as PudMed, Google Scholar, and OVID. After researching the topic, recommendations and interventions to fix the problem were found. According to QSEN (2019), pursuing information regarding outcomes in care, and identifying practice gaps is a vital skill to form when practicing in the nursing field. Huber (2018) mentions that nurses in leadership positions addressing quality improvement must have “a devotion to data collection and analysis as the foundation of problem solving.” When research and data is collected it is up to the nurse’s judgement whether these recommendations or findings will be utilized to improve the quality of care on their unit.
Valizadeh, Mirlashari, Navab, Higman, and Ghorbani (2018) conducted a phenomenological study to examine the neglect of fathers in family-centered care (FCC) and the nurses role in fostering FCC in the NICU. This study, guided by Heideggerian philosophy, included nurses working in the NICU for at least three years and three different level three NICUs (Valizadeh et al., 2018). Valizadeh et al. (2018) stated father participants explained that they were limited educational and participation opportunities available during their NICU experience, and if they were offered such opportunities they reacted enthusiastically to the nurses efforts to get them involved in the infant’s care (Valizadeh et al., 2018). They further discovered that nurses play an imperative role in establishing paternal attachment with the infant (Valizadeh et al., 2018). Another phenomenological study recruited and interviewed seven fathers of infants and analyzed their experience on level three NICUs of two hospitals (Logan & Dormire, 2018). With their findings they recommended that nursing staff promote paternal engagement and involvement, educate on the importance of frequent visitations, and recognize opportunities for fathers to practice skin to skin contact (Logan & Dormire, 2018). Lastly, they specifically state that nurses should explain medical terms, test results, diaper changes, and skills to console the infant to the fathers to increase bonding cohesion (Logan & Dormire, 2018).
Similarly, to the study conducted by Logan and Dormire (2018), a qualitative study conducted by Noergaard, Johannessen, Fenger-Gron, Kofoed, and Ammentorp (2018) interviewed and observed fathers in NICU. The authors also questioned nursing staff on how they involved fathers in their care of their infant during this period (Noergaard et al., 2018). Noergaard et al. (2018) suggested that nurses help destroy preconceived notions of masculinity, and help fathers see that they are just as essential as the mothers during their infant’s NICU stay. Nurses should also inform the fathers directly about their infant’s condition and include them in infant care. (Noergaard et al., 2018). A qualitative study done by Feeley et al. (2016) dives deeper into parent and nurse relationship in the NICU. Through their data analysis the authors discovered that parents and nurses helped establish closeness with the use of decision-making strategies, organization of care, and support provided by the nurses to the parents (Feeley et al., 2016).
A study done by Kadiva and Mozafarinia (2013) examined paternal knowledge deficiency and stress in the NICU. In their study they discuss the integration of nursing staff to support and lead fathers throughout their infant’s journey in the NICU (Kadiva & Mozafarinia, 2013). The authors designated twenty-three fathers to the control group and twenty-three fathers to the intervention group (Kadiva & Mozafarinia, 2013). Kadiva and Mozafarinia’s (2013) interventions of a HUG Your Baby DVD and a “family-friendly educational program” resulted in an increase in paternal knowledge and confidence. Years later, Fisher et al. (2018) discussed their review of literature regarding fathers in the NICU and the benefits of establishing a paternal-infant bond. The authors state that mother and father interaction and education should be equal; they offer twelve recommendations to improve the practices (Fisher et al., 2018). Some of the recommendations for the NICU staff to address include: accessible access to the NICU for fathers, improved communication, a creation of a father auditing tool, training for staff to working more efficiently with fathers, and education provided by nursing staff on co-parenting (Fisher et al., 2018).
A study done by Varela, Tessier, Tarabulsy and Pierce (2017) focused more on a specific intervention to facilitate bonding known as SSC. The authors recruited forty-nine fathers in the NICU and tested their cortisol levels and blood pressure during SSC (Varela et al., 2017). They concluded that they was a substantial decrease in physiological stress responses from the fathers, and recommended that hospitals continue to enforce and practice SSC to assist in bonding in the NICU (Varela et al., 2017). In an additional randomized controlled trail conducted by Chen, Gau, Liu, and Lee (2017) they observed the effects of SSC on paternal-infant attachment. The authors’ study included eighty-three fathers; the intervention group received standard care, an “Early Childcare for Fathers” pamphlet, and practiced SSC (Chen et al., 2017). With the use of a Father-Child Attachment Scale, the authors were able to conclude that attachment was higher in the intervention group than the control group (Chen et al., 2017). They further recommended that nursing staff provide educational pamphlets and demonstrations, while encouraging fathers to participate in their care of their infant (Chen et al., 2017).
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Mahon, Albersheim, and Holsti (2015) highlights the evaluation of paternal satisfaction and support needs within the NICU. Mahon et al. (2015) study supports the use of Fathers’ Support Scale: Neonatal Intensive care unit (FSS:NICU) to evaluate paternal needs and plan accordingly to the father’s response. Lastly, a qualitative study done by Feeley, Waitzer, Sherrard, Boisvert, and Zelkowitz (2012) interviewed eighteen fathers in the NICU and recorded their perceptions of difficulties and aids in NICU that affected their participation involvement (Feeley et al., 2012). Three categories were acknowledged: infant factors, interpersonal factors, and NICU environmental factors (Feeley et al., 2012). In conclusion, the authors suggested that nurses should be concise in their education, provide demonstrations, and explain potential boundaries to care (Feeley et al., 2012).
To help address and fix the problem of paternal-infant bonding in the NICU, an intervention involving nursing education and enforcement of practices will be explored throughout this section of the paper. This intervention of educational sessions and demonstrations of bonding techniques will be offered to fathers of infants in the NICU. Nursing staff will be first provided with educational material and detailed instructions about paternal-infant bonding followed by being implementors of providing education and demonstrations to fathers on the unit. A leadership theory called transformational leadership, a management style theory called systems theory, and change model known as Lewin’s Change Process will help explain the direction of the planned intervention. Transformational leadership is defined as someone who helps their followers perform to the expected level with the use of guidance and change techniques (Huber, 2018, p. 13). Systems theory highlights that change or shift in one part of the system affects the system as a whole (Huber, 2018, p. 25). Lastly, Lewin’s Change of Process Model involves “used ideas of equilibrium within systems.” (Huber, 2018, p. 35).
To begin this proposed change a leadership nurse will need to go through the phases of Lewin’s Change Process, which involves unfreezing, moving, and refreezing. The first step will be the unfreezing phase. In this phase the nurse leader will hold a meeting addressing the topic of change (paternal-infant bonding). In this meeting the leadership nurse will inquire what the staff already knows about paternal-infant bonding, lack of education on the topic, and discuss why more education and enforcement of techniques should be offered to fathers in the NICU by nursing staff. Fisher et al. (2018) stated in their review that some nurses tended to run into more “difficulty” relating to fathers compared to mothers, with this result, they recommended that staff training be mandatory for nurses for strategies on how to engage with fathers and increase their involvement in the NICU. In this phase the leadership nurse will use transformational leadership techniques such as presenting the topic in charismatic attitude to help staff correctly implement the change on the unit. Like, transformational leadership, the leadership nurse will also push nursing staff to rise above their owns needs to meet the needs of father within the NICU (Huber, 2018, p. 13).
The next step of the process is the moving phase. The moving phase involves planning and implementation (Huber, 2018, p. 35). Based of Fisher’s et al. (2018) recommendation of mandatory training, the leadership nurse will provide the staff with an educational class that will take place in the NICU and last one week. This class will address ways to engage the father in care of their infant and promote bonding through the use of visual aids and demonstrations. The nurse will then use Logan and Dormire’s (2018) proposal of including information on: SCC, when opportunities for care are appropriate for the fathers, educational necessities the father needs to know about their infant, and bonding techniques. Since it was founded that fathers act eager to such opportunities of participation (Valizadeh et al., 2018). The visual aids will also include qualitative data collected from paternal experiences within the NICU, and include the reports of fathers feelings of “powerlessness” and “exclusion” (Fisher et al., 2018). After nursing staff has been through the course they will be ready to implement the intervention of education and enforcement to fathers on the unit.
In the last step, the refreezing phase, the leadership nurse will use systems theory to explain to staff that once this proposed change of education and enforcement of bonding is implemented paternal experience in the NICU will change as a whole. During this phase evaluation and any question to change happens (Huber, 2018, p.35). In the phase the leadership nurse will educate staff on the potential barriers and restrictions to this purposed change. The leadership nurse will explain to staff to keep in mind systems theory’s idea of, all the parts relate back to the main goal, in this case the goal is improving paternal-infant bonding.
evaluate how well the nurses have been implementing changes on the unit. To do so, the leadership nurse will use father-friendly service auditing tool that
- Chen, E., Gau, M., Liu, C., & Lee, T. (2017). Effects of father-neonate skin-to-skin contact on attachment: A randomized controlled trial. Nursing Research and Practice,2017, 1-8. doi:10.1155/2017/8612024
- Feeley, N., Genest, C., Niela-Vilén, H., Charbonneau, L., & Axelin, A. (2016). Parents and nurses balancing parent-infant closeness and separation: A qualitative study of NICU nurses’ perceptions. BMC Pediatrics,16(1). doi:10.1186/s12887-016-0663-1
- Feeley, N., Waitzer, E., Sherrard, K., Boisvert, L., & Zelkowitz, P. (2012). Fathers’ perceptions of the barriers and facilitators to their involvement with their newborn hospitalized in the neonatal intensive care unit. Journal of Clinical Nursing,22(3-4), 521-530. doi:10.1111/j.1365-2702.2012.04231.x
- Fisher, D., Khashu, M., Adama, E. A., Feeley, N., Garfield, C. F., Ireland, J., . . . Teijlingen, E. V. (2018). Fathers in neonatal units: Improving infant health by supporting the baby-father bond and mother-father coparenting. Journal of Neonatal Nursing,24(6), 306-312. doi:10.1016/j.jnn.2018.08.007
- Huber, D. L. (2018). Leadership & Nursing Care Management (6th ed.). St. Louis: Elsevier.
- Kadivar, M., & Mozafarinia, S. M. (2013). Supporting fathers in a NICU: Effects of the hug your baby program on fathers’ understanding of preterm infant behavior. The Journal of perinatal education, 22(2), 113–119. doi:10.1891/1058-1243.22.2.113
- Logan, R. M., & Dormire, S. (2018). Finding my way. Advances in Neonatal Care,18(2), 154-162. doi:10.1097/anc.0000000000000471
- Mahon, P., Albersheim, S., & Holsti, L. (2015). The fathers support scale: Neonatal intensive care unit (FSS:NICU): Development and initial content validation. Journal of Neonatal Nursing,21(2), 63-71. doi:10.1016/j.jnn.2014.09.007
- Noergaard, B., Johannessen, H., Fenger-Gron, J., Kofoed, P., & Ammentorp, J. (2018). Fathers’ needs and masculinity dilemmas in a neonatal intensive care unit. Journal of Intensive and Critical Care,04(04). doi:10.21767/2471-8505.100119
- Quality and Safety Education for nurses. (2019). QSEN competencies. Retrieved from http://qsen.org/competencies/pre-licensure-ksas/#quality_improvement
- Valizadeh, S., Mirlashari, J., Navab, E., Higman, W., & Ghorbani, F. (2018). Fathers: The lost ring in the chain of family-centered care-A phenomenological study in neonatal Intensive care units of Iran. Advances in Neonatal Care,18(1), E3-E11. doi:10.1097/ANC.0000000000000449
- Varela, N., Tessier, R., Tarabulsy, G., & Pierce, T. (2017). Cortisol and blood pressure levels decreased in fathers during the first hour of skin-to-skin contact with their premature babies. Acta Paediatrica,107(4), 628-632. doi:10.1111/apa.14184
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