How to Support & Dealing How to Support & Dealing with parents in NICUwith parents in NICU

Dr.Osama Arafa Abd Dr.Osama Arafa Abd EL HameedEL Hameed

M. B.,B.CH - M.Sc Pediatrics - Ph. M. B.,B.CH - M.Sc Pediatrics - Ph. D.D.

Pediatrics & NeonatologyPediatrics & NeonatologyConsultantConsultant

Head of Pediatrics Head of Pediatrics Department - Port-Fouad Department - Port-Fouad

HospitalHospital

Challenges to Parenting in the Challenges to Parenting in the NICUNICU

Separation and distanceSeparation and distance Stress, anxiety, loss, fatigueStress, anxiety, loss, fatigue Infant appearance and behavior Infant appearance and behavior Nursery appearance and policiesNursery appearance and policies Lack of privacy and controlLack of privacy and control Staff-parent interactionsStaff-parent interactions Financial concernsFinancial concerns Family issuesFamily issues

Parental Feelings After Preterm Parental Feelings After Preterm BirthBirth

GriefGrief FearFear HopeHope AngerAnger HelplessnessHelplessness Thinking about baby Thinking about baby

continuallycontinually Loss of controlLoss of control Loss of role as decision Loss of role as decision

maker and caregivermaker and caregiver

AnxietyAnxiety HappinessHappiness ShockShock RestlessnessRestlessness EmptinessEmptiness DepressionDepression FrustrationFrustration DistressDistress Stress disordersStress disorders

Difficult Times in the NICUDifficult Times in the NICU

• Still unable to see babyStill unable to see baby• First visit to the NICUFirst visit to the NICU• Being discharged without babyBeing discharged without baby• Difficult newsDifficult news• TransitionsTransitions• Discharge home with babyDischarge home with baby• Death of baby in unitDeath of baby in unit

Parent Needs in the NICU Parent Needs in the NICU (Cleveland, (Cleveland, 2008; Hurst, 2001)2008; Hurst, 2001)

Accurate information and inclusion in the Accurate information and inclusion in the infant's careinfant's care

Vigilant watching over and protection of Vigilant watching over and protection of the infantthe infant

Contact with the infantContact with the infant Being positively perceived by the nursery Being positively perceived by the nursery

staffstaff Individualized careIndividualized care Therapeutic relationship with staffTherapeutic relationship with staff

Psychological Stress in NICU Psychological Stress in NICU ParentsParents

Parents of infants in the NICU are at Parents of infants in the NICU are at increased risk of depression and stress increased risk of depression and stress disorders both during the infant’s disorders both during the infant’s hospitalization and in the postdischarge hospitalization and in the postdischarge periodperiod Acute stress and distressAcute stress and distress Posttraumatic stress disorderPosttraumatic stress disorder AnxietyAnxiety Depression/postpartum mood disordersDepression/postpartum mood disorders(Beck, 2003; Groer et al, 2002; Howland et al, 2011; Padovani et al, 2009; Poehlmann et al, 2009; Shaw et al, 2009)

Stress and DistressStress and Distress StressStress:: “...a physical, chemical, or “...a physical, chemical, or

emotional factor that causes bodily or emotional factor that causes bodily or mental tension and may be recognized mental tension and may be recognized as a factor in disease causationas a factor in disease causation.” .” (Merriam Webster's Collegiate Dictionary)(Merriam Webster's Collegiate Dictionary)

DistressDistress: : adverse effects seen when a adverse effects seen when a stress causing event has exceeded stress causing event has exceeded the human limits of stress tolerancethe human limits of stress tolerance

Consequences of StressConsequences of Stress During pregnancy = increase risk of During pregnancy = increase risk of

preterm labor and birthpreterm labor and birth

Postpartum: early stressful experiences Postpartum: early stressful experiences can subsequently affect parental attitudes, can subsequently affect parental attitudes, behaviors and care giving relationshipbehaviors and care giving relationship

Long term health risks for parents and Long term health risks for parents and infantsinfants

Acute Stress DisorderAcute Stress Disorder Significant stressor Significant stressor

Initial "daze“ and disorientation, Initial "daze“ and disorientation, followed by symptoms such as followed by symptoms such as depression, anxiety, anger, despair, depression, anxiety, anger, despair, over activity, withdrawal over activity, withdrawal

Usually diminishes after 24–48 hoursUsually diminishes after 24–48 hours

Critical Features of Postpartum Critical Features of Postpartum Mood DisordersMood Disorders (Siegel, Gardner & Dickey, (Siegel, Gardner & Dickey,

2011)2011) Over concern for the baby or excessive Over concern for the baby or excessive

anxiety over the infant’s healthanxiety over the infant’s health Feelings of guilt , inadequacy, Feelings of guilt , inadequacy,

worthlessness, failure at mother hoodworthlessness, failure at mother hood Fear of losing control or “going crazy”Fear of losing control or “going crazy” Lack of interest in the babyLack of interest in the baby Fear of harming the babyFear of harming the baby ObsessionObsession

Post-traumatic Stress Disorder Post-traumatic Stress Disorder (DSM-IV-TR)(DSM-IV-TR)

Exposure to traumatic eventExposure to traumatic event Re-experiencing the event through intrusive Re-experiencing the event through intrusive

thoughtsthoughts Avoidance of stimuli that represent the eventAvoidance of stimuli that represent the event Increased arousal after the event that was not Increased arousal after the event that was not

present beforepresent before Duration of >1 monthDuration of >1 month Significant impairment in social or other Significant impairment in social or other

functioningfunctioning Reported among parents of VLBWReported among parents of VLBW

Post Traumatic Stress and NICU Post Traumatic Stress and NICU FamiliesFamilies

Wereszczak et al. (1997)Wereszczak et al. (1997) Qualitative study of vividness of memories Qualitative study of vividness of memories

primary caregivers recall 3 years post preterm primary caregivers recall 3 years post preterm birth (n = 44)birth (n = 44)

Vivid memories related to infant appearance and Vivid memories related to infant appearance and behavior, pain, procedures, illness severity, and behavior, pain, procedures, illness severity, and uncertainty of outcomesuncertainty of outcomes

Holditch-Davis et al (2003)Holditch-Davis et al (2003) PTSD questionnaire and interview of 30 PT PTSD questionnaire and interview of 30 PT

mothers at 6 mo corrected agemothers at 6 mo corrected age All had at least 1 PTSD symptom, 12 had 2, 16 All had at least 1 PTSD symptom, 12 had 2, 16

had 3had 3 PTSD symptoms associated with infant illness PTSD symptoms associated with infant illness

severity severity

Post Traumatic Stress and NICU Post Traumatic Stress and NICU FamiliesFamilies

Pierrhumbert et al. (2003)Pierrhumbert et al. (2003) PTSD questionnaire to parents (50 PT, 25 FT) at PTSD questionnaire to parents (50 PT, 25 FT) at

6 mo6 mo 67% of mothers of preemies vs. 6% controls 67% of mothers of preemies vs. 6% controls

exhibited clinical post-traumatic reactionsexhibited clinical post-traumatic reactions Intensity correlated with eating/sleeping Intensity correlated with eating/sleeping

problems of infantsproblems of infants

Kersting et al. (2004)Kersting et al. (2004) PTS responses (scale) in 50 PT vs 30 FT mothers PTS responses (scale) in 50 PT vs 30 FT mothers

at 5 times from birth to 14 monthsat 5 times from birth to 14 months Higher rates and similar intensity of traumatic Higher rates and similar intensity of traumatic

symptoms in PT mothers at all time points to 14 symptoms in PT mothers at all time points to 14 monthsmonths

Post Traumatic Stress and NICU Post Traumatic Stress and NICU FamiliesFamilies

Shaw et al. (2009)Shaw et al. (2009) Prevalence of ASD (birth) and PTSD 4 months after the Prevalence of ASD (birth) and PTSD 4 months after the

birth of PT or sick NB (n = 18) birth of PT or sick NB (n = 18) 33% of fathers, 9% of mothers met criteria for PTSD33% of fathers, 9% of mothers met criteria for PTSD ASD symptoms correlated with PTSD and depressionASD symptoms correlated with PTSD and depression Fathers: PTSD more delayed onset, greater risk by 4 moFathers: PTSD more delayed onset, greater risk by 4 mo

Vanderbilt (2009)Vanderbilt (2009) Assessment of postpartum acute PTS and depression in Assessment of postpartum acute PTS and depression in

59 NICU & 60 well NB mothers in first week after birth59 NICU & 60 well NB mothers in first week after birth NICU mothers show increased symptoms of acute PTS NICU mothers show increased symptoms of acute PTS

stress and depression. 23% NICU and 3% well NB stress and depression. 23% NICU and 3% well NB reached severity criteria for acute stress disorderreached severity criteria for acute stress disorder

Enhancing Parenting and Reducing Enhancing Parenting and Reducing StressStress

Emotional supportEmotional support

Supportive environmentSupportive environment

Understanding infant behavior and Understanding infant behavior and characteristicscharacteristics

Involvement in caregiving and decision makingInvolvement in caregiving and decision making

Knowledge, sensitivity, skillsKnowledge, sensitivity, skills

Skin to skin holding (kangaroo care)Skin to skin holding (kangaroo care)

Parent Emotional Support Parent Emotional Support (O’Donnell, 1996)(O’Donnell, 1996)

Help parents understand their responses and Help parents understand their responses and their partner’s responsestheir partner’s responses

Provide information and empathyProvide information and empathy Assist in interpreting informationAssist in interpreting information Respond to all questions fully and openlyRespond to all questions fully and openly Support family from within their perspectiveSupport family from within their perspective Respect responsesRespect responses Repeat explanationsRepeat explanations Flexibility and availability to talk with family Flexibility and availability to talk with family

when they are readywhen they are ready

Supportive EnvironmentSupportive Environment Family centered careFamily centered care

Continuity of careContinuity of care

Parent to parent supportParent to parent support

Partnering with parentsPartnering with parents

Transition to homeTransition to home

Family-Centered Care Family-Centered Care Supports development of parental Supports development of parental

competence competence

Focuses on:Focuses on: Identifying and building on individual and Identifying and building on individual and

family strengthsfamily strengths Partnering and collaborating with parentsPartnering and collaborating with parents Empowering families so they can care for Empowering families so they can care for

their infant in the NICU and at hometheir infant in the NICU and at home(Griffin & Abraham, 2006; IFCC, 1998; Saunders et al., 2003)(Griffin & Abraham, 2006; IFCC, 1998; Saunders et al., 2003)

Key Components of Parent Key Components of Parent SupportSupport

Parents are respected and valued members of Parents are respected and valued members of the health care teamthe health care team

Parents and health professionals form Parents and health professionals form effective partnershipseffective partnerships

The focus is on parental strengths; parents The focus is on parental strengths; parents define their own needs and prioritiesdefine their own needs and priorities

(Hurst, 2001, 2006; Cooper et al, 2007; Gooding, 2008)(Hurst, 2001, 2006; Cooper et al, 2007; Gooding, 2008)

Key Components of Parent Key Components of Parent SupportSupport

• All parents can give and receive; teach and learn; All parents can give and receive; teach and learn; care and be cared forcare and be cared for

• Parents are viewed in the context of their families, Parents are viewed in the context of their families, neighborhoods or communitiesneighborhoods or communities

• Parent support services are accessibleParent support services are accessible

• Information shared by parents is confidentialInformation shared by parents is confidential

(Hurst, 2001, 2006; Cooper et al, 2007; Gooding, 2008)(Hurst, 2001, 2006; Cooper et al, 2007; Gooding, 2008)

Promoting Parenting in the Promoting Parenting in the NICUNICU

• Provide support to parentsProvide support to parents• Help parents identify and use support Help parents identify and use support

systemssystems• Collaborate with families in planning and Collaborate with families in planning and

providing careproviding care• Enhance the role of parents as advocates for Enhance the role of parents as advocates for

their infanttheir infant• Empower parents to care for their infant, Empower parents to care for their infant,

participate in rounds, ask questions, meet participate in rounds, ask questions, meet with the care team, etc.with the care team, etc.

EmpowermentEmpowerment• To equip or supply with an ability; enableTo equip or supply with an ability; enable• Helping processHelping process• Caring presence building on parents Caring presence building on parents

strengthsstrengths• Active participation with increasing controlActive participation with increasing control• Sharing of knowledge and skillsSharing of knowledge and skills• Partnership with mutual decisions, choices Partnership with mutual decisions, choices

and responsibilityand responsibility• Enabling or transferring power to the otherEnabling or transferring power to the other

Family Support and Family Support and EmpowermentEmpowerment

Partnership between NICU care provider and Partnership between NICU care provider and parent/family = interdependency and parent/family = interdependency and collaboration collaboration (Gibbins et al, 2008; Lawhon, 1997)(Gibbins et al, 2008; Lawhon, 1997)

““Unique and vital contribution of both the family Unique and vital contribution of both the family and the care provider to the infant’s health and and the care provider to the infant’s health and well being” well being” (Gibbins et al, 2008)(Gibbins et al, 2008)

Creating Opportunities for Parent Empowerment Creating Opportunities for Parent Empowerment (COPE) (COPE) (Melynk et al, 2006)(Melynk et al, 2006)

Kangaroo Care Parenting Effects Kangaroo Care Parenting Effects (Dodd, 2004; Feldman, 2004; Feldman & Eidelman, 2003; Ludington-(Dodd, 2004; Feldman, 2004; Feldman & Eidelman, 2003; Ludington-

Hoe et al, 2008Hoe et al, 2008))

Skin-to-skin contact between infant and parent Skin-to-skin contact between infant and parent provides high levels of comfort to parents provides high levels of comfort to parents (Cooper et (Cooper et al, 2007)al, 2007)

Benefits to attachmentBenefits to attachment Contingent stimulationContingent stimulation Sensory environment of breast Sensory environment of breast

ParentalParental Reduced anxiety, stressReduced anxiety, stress Increased parental bonding and satisfactionIncreased parental bonding and satisfaction Parent comfortParent comfort

Attachment Behaviors of Attachment Behaviors of Parents of NICU Infants Parents of NICU Infants (Gale & (Gale &

Franck, 1998)Franck, 1998) Eagerly performs caregiving activitiesEagerly performs caregiving activities Expresses pleasure in meeting infant Expresses pleasure in meeting infant

needsneeds Able to comfort infant when distressedAble to comfort infant when distressed Brings toys, other items to personalize Brings toys, other items to personalize

infant’s spaceinfant’s space Makes personalized observations Makes personalized observations

about infantabout infant

Offers suggestions and makes demands Offers suggestions and makes demands for personalized carefor personalized care

Demonstrates advocacy behaviorsDemonstrates advocacy behaviors Feels knows and can care for infant better Feels knows and can care for infant better

than anyone elsethan anyone else Demonstrates consistent visiting and/or Demonstrates consistent visiting and/or

calling patternscalling patterns Questions focus on total infants, not only Questions focus on total infants, not only

physiological parametersphysiological parameters

Attachment Behaviors of Attachment Behaviors of Parents of NICU InfantsParents of NICU Infants (Gale & (Gale &

Franck, 1998Franck, 1998

The Role of the Neonatal NurseThe Role of the Neonatal Nurse• Recognize and accept their role in discharge Recognize and accept their role in discharge

managementmanagement• Work collaboratively with families in facilitating Work collaboratively with families in facilitating

the transition to home from admission onwardthe transition to home from admission onward• Develop evidence-based practice guidelines Develop evidence-based practice guidelines

consistent with current knowledge and researchconsistent with current knowledge and research

Continuum of CareContinuum of Care• Nurses link care across units, before Nurses link care across units, before

admission and after discharge, in hospital admission and after discharge, in hospital systems and with external sites.systems and with external sites.

• Efforts focus on communication, Efforts focus on communication, information, policies and practices.information, policies and practices.

• Each shift team should work with the next Each shift team should work with the next team or provider to facilitate consistency team or provider to facilitate consistency and continuity.and continuity.

Parent EducationParent Education• The nurse ensures that parents have the The nurse ensures that parents have the

knowledge and skills they need for the knowledge and skills they need for the infant’s transition to home.infant’s transition to home.

• The nurse individualizes teaching content The nurse individualizes teaching content for each family based on the family’s for each family based on the family’s needs and priorities, which the family and needs and priorities, which the family and staff determine together staff determine together (Griffin & Abraham, 2006).(Griffin & Abraham, 2006).

• Each family needs at least two caregivers.Each family needs at least two caregivers.• As much teaching as possible should As much teaching as possible should

occur before discharge occur before discharge (Broedsgaard & Wagner, (Broedsgaard & Wagner, 2005; Griffin & Abraham, 2006).2005; Griffin & Abraham, 2006).

Parent Education TopicsParent Education Topics

Feeding Topics for Parent Feeding Topics for Parent EducationEducation

• Hunger and satiation cuesHunger and satiation cues• Positioning, rooting and sucking reflexesPositioning, rooting and sucking reflexes• Breaking suctionBreaking suction• BurpingBurping• Schedule vs. demandSchedule vs. demand• Duration and volume of feedingsDuration and volume of feedings• Latching on and letting downLatching on and letting down• Formula typeFormula type• Correct preparation of formulaCorrect preparation of formula

Choosing a Primary Care Choosing a Primary Care ProviderProvider

• Helping families select a primary care Helping families select a primary care provider can:provider can: Reduce anxietyReduce anxiety Ensure that a provider is in place at Ensure that a provider is in place at

the time of dischargethe time of discharge Allow provider involvement during Allow provider involvement during

the discharge processthe discharge process• Nurses should encourage parents to meet Nurses should encourage parents to meet

with potential providers to help make their with potential providers to help make their selection.selection.

BreastfeedingBreastfeeding• In the first few weeks, regular and In the first few weeks, regular and

frequent pumping is important to frequent pumping is important to establish milk supply establish milk supply (Isaacson, 2006; Spatz, (Isaacson, 2006; Spatz, 2004, 2006).2004, 2006).

• Kangaroo care Kangaroo care (Brodsky & Ouellette, 2008; Ludington-(Brodsky & Ouellette, 2008; Ludington-Hoe et al., 2008; Nye, 2008; Spatz, 2006):Hoe et al., 2008; Nye, 2008; Spatz, 2006):

Promotes earlier breastfeeding and maternal Promotes earlier breastfeeding and maternal milk supplymilk supply

Increases the number of mothers breastfeeding Increases the number of mothers breastfeeding at NICU dischargeat NICU discharge

Increases the duration of breastfeedingIncreases the duration of breastfeeding

BottlefeedingBottlefeeding• Nurses should teach formula preparation, Nurses should teach formula preparation,

including mixing instructions and type of including mixing instructions and type of water to use.water to use.

• The primary care provider needs to know The primary care provider needs to know water fluoride content to decide whether water fluoride content to decide whether or not to supplement.or not to supplement.

• Parents should clean utensils with hot, Parents should clean utensils with hot, soapy water and a bottle and nipple brush; soapy water and a bottle and nipple brush; sterilization is not necessary.sterilization is not necessary.

Behavioral CuesBehavioral Cues• Engagement cues (stability cues) indicate Engagement cues (stability cues) indicate

that the infant is coping well.that the infant is coping well.• Disengagement cues (stress or instability Disengagement cues (stress or instability

cues) signal that the infant is becoming cues) signal that the infant is becoming stressed or overloaded.stressed or overloaded.

• Parents, nurses and other care providers Parents, nurses and other care providers must be sensitive to infant cues and must be sensitive to infant cues and respond appropriately.respond appropriately.

Engagement CuesEngagement Cues• Relaxed tone with smooth movementsRelaxed tone with smooth movements• Extremities flexedExtremities flexed• Quiet, alert stateQuiet, alert state• Animated face with bright eyesAnimated face with bright eyes• Periodic eye contact with caregiverPeriodic eye contact with caregiver• Hand-to-mouth movementsHand-to-mouth movements• Turning toward a voiceTurning toward a voice• SmilingSmiling• Well-perfused, oxygenated appearanceWell-perfused, oxygenated appearance

Disengagement CuesDisengagement Cues

• Averted gazeAverted gaze• Falling asleepFalling asleep• YawningYawning• Frowning or Frowning or

grimacinggrimacing• ArchingArching• Gagging, grunting Gagging, grunting

or sneezingor sneezing

• Hiccupping, spitting Hiccupping, spitting or gaggingor gagging

• Splayed fingersSplayed fingers• CryingCrying• Becoming pale, Becoming pale,

mottled or redmottled or red

Take Home MessageTake Home Message

We admit babies to the Neonatal Intensive Care Unit We admit babies to the Neonatal Intensive Care Unit (NICU), because they need specialized medical and (NICU), because they need specialized medical and nursing care.nursing care.

We recognize that, this can be a very stressful and We recognize that, this can be a very stressful and confusing time for parents and family.confusing time for parents and family.

Separation from your new baby is difficult .Separation from your new baby is difficult .

Understanding the needs of your baby will help you get Understanding the needs of your baby will help you get through this difficult time.through this difficult time.

You may have many questions about the care your You may have many questions about the care your baby will receive. We try to help answer many of these baby will receive. We try to help answer many of these questions.questions.

Our first priority is the care and health of your family.Our first priority is the care and health of your family.

We want to work with you to meet your baby’s needs. We want to work with you to meet your baby’s needs. Please ask questions or discuss concerns with your Please ask questions or discuss concerns with your baby’s nurse or doctor.baby’s nurse or doctor.

We want to make your baby’s stay with us as positive We want to make your baby’s stay with us as positive as possible.as possible.

Selected ReferencesSelected References Ashton, M, Meagher-Stewart, D, et al. (2006). Family Ashton, M, Meagher-Stewart, D, et al. (2006). Family

health nursing and empowering relationships. Pediatr health nursing and empowering relationships. Pediatr Nurs, 32, 61-67Nurs, 32, 61-67

Cooper, L.G., Gooding, J.S., et al. (2007). Impact of a Cooper, L.G., Gooding, J.S., et al. (2007). Impact of a Family-Centered Care Initiative on NICU Care, Staff Family-Centered Care Initiative on NICU Care, Staff and Families. Journal of Perinatology, 27, S32-S37. and Families. Journal of Perinatology, 27, S32-S37.

Feeley, N., Zelkowitz, P. et al. (2011). Posttraumatic Feeley, N., Zelkowitz, P. et al. (2011). Posttraumatic stress among mothers of very low birthweight infants stress among mothers of very low birthweight infants at 6 months after discharge from the neonatal at 6 months after discharge from the neonatal intensive care unit. Appl Nurs Res, 24, 114-117.intensive care unit. Appl Nurs Res, 24, 114-117.

Feldman, R, Eidelman, A, et al. (2002). A comparison Feldman, R, Eidelman, A, et al. (2002). A comparison of skin-to-skin (kangaroo) and traditional care, of skin-to-skin (kangaroo) and traditional care, parenting outcomes and preterm infant parenting outcomes and preterm infant development. Pediatrics,, 110-16-26.development. Pediatrics,, 110-16-26.

Selected ReferencesSelected References Gibbins, S., et al. (2008). The universe of Gibbins, S., et al. (2008). The universe of

developmental care, a new conceptual model for developmental care, a new conceptual model for application in the neonatal intensive care unit. Adv application in the neonatal intensive care unit. Adv Neonat Care, 8, 141-148.Neonat Care, 8, 141-148.

Gooding, J.S., Cooper, L.G., et al. (2011). Family Gooding, J.S., Cooper, L.G., et al. (2011). Family support and family-centered care in the neonatal support and family-centered care in the neonatal intensive care unit: origins, advances, impact. Semin intensive care unit: origins, advances, impact. Semin Perinatol, 35, 20-28.Perinatol, 35, 20-28.

Howland, L.C., Pickler, R.H., et al. (2011). Exploring Howland, L.C., Pickler, R.H., et al. (2011). Exploring biobehavioral outcomes in mothers of preterm infants. biobehavioral outcomes in mothers of preterm infants. Am J Matern Child Nurs, 36, 91-97Am J Matern Child Nurs, 36, 91-97

Lawhon, g. (1997). Proving developmentally supportive Lawhon, g. (1997). Proving developmentally supportive care in the newborn intensive care unit: An evolving care in the newborn intensive care unit: An evolving challenge. J Perinat Neonat Nurs, 10 (4), 48-61.challenge. J Perinat Neonat Nurs, 10 (4), 48-61.

Selected ResourcesSelected Resources Lefkowitz, D.S., Baxt, C. & Evans, J.R. (2010). Prevalence Lefkowitz, D.S., Baxt, C. & Evans, J.R. (2010). Prevalence

and correlates of posttraumatic stress and postpartum and correlates of posttraumatic stress and postpartum depression in parents of infants in the Neonatal Intensive depression in parents of infants in the Neonatal Intensive Care Unit (NICU). J Clin Psychol Med Settings, 17, 230-237.Care Unit (NICU). J Clin Psychol Med Settings, 17, 230-237.

Ludington-hoe, S., Morgan, K. & Abouelfettoh, A. (2008). A Ludington-hoe, S., Morgan, K. & Abouelfettoh, A. (2008). A clinical guideline for implementation of kangaroo care with clinical guideline for implementation of kangaroo care with premature infants of 30 or more weeks post-menstrual age. premature infants of 30 or more weeks post-menstrual age. Adv Neonat Care, 8(Supplement),S3-S23.Adv Neonat Care, 8(Supplement),S3-S23.

Melnyk, B.M., et al. (2006). Reducing premature infants' Melnyk, B.M., et al. (2006). Reducing premature infants' length of stay and improving parents' mental health length of stay and improving parents' mental health outcomes with the Creating Opportunities for Parent outcomes with the Creating Opportunities for Parent Empowerment (COPE) neonatal intensive care unit Empowerment (COPE) neonatal intensive care unit program: a randomized, controlled trial. Pediatrics, 118, program: a randomized, controlled trial. Pediatrics, 118, e1414-e1427.e1414-e1427.

Selected ResourcesSelected Resources Moore, K.A., et al. (2003). Implementing potentially Moore, K.A., et al. (2003). Implementing potentially

better practices for improving family-centered care in better practices for improving family-centered care in neonatal intensive care units: successes and neonatal intensive care units: successes and challenges. challenges. Pediatrics, Pediatrics, 111(4 Pt 2), e450-460.111(4 Pt 2), e450-460.

Shaw, R.J., et al. (2009). The relationship between Shaw, R.J., et al. (2009). The relationship between acute stress disorder and posttraumatic stress disorder acute stress disorder and posttraumatic stress disorder in the neonatal intensive care unit. Psychosomatics, in the neonatal intensive care unit. Psychosomatics, 50, 131-137.50, 131-137.

Sweeney, M.M. (1997). The value of a family-centered Sweeney, M.M. (1997). The value of a family-centered approach in the NICU and PICU: one family's approach in the NICU and PICU: one family's perspective. Pediatric Nursing, 23, 64-66.perspective. Pediatric Nursing, 23, 64-66.

Voos, K.C., et al. (2011). Effects of implementing Voos, K.C., et al. (2011). Effects of implementing family-centered rounds (FCRs) in a neonatal intensive family-centered rounds (FCRs) in a neonatal intensive care unit (NICU). J Matern Fetal Neonatal Med, 24, 1-4.care unit (NICU). J Matern Fetal Neonatal Med, 24, 1-4.

THANK YOU