1. Kutahyalioglu, Nesibe S. PhD, RN
  2. Scafide, Katherine N. PhD, RN
  3. Mallinson, Kevin R. PhD, RN, FAAN
  4. D'Agata, Amy L. PhD, RN


Background: Approximately 7 out of every 100 births in the United States result in admission to the neonatal intensive care unit (NICU), which contributes to a delay in initial physical contact between the parents and their newborn. While family-centered care (FCC) increases opportunities for parent-infant connection, implementation barriers persist in clinical practice. Research has yet to examine whether organizational and nursing factors of empowerment and compassion fatigue (CF) in the NICU are associated with FCC practice.


Purpose: The aim of this study was to determine the relationship between empowerment, CF, and FCC practices among NICU nurses.


Methods: This quantitative portion of a mixed-methods study used a cross-sectional, descriptive correlational design. Bedside NICU nurses with at least 6-month experience were recruited to complete an anonymous online survey using established, valid, and reliable instruments.


Results: Except for organizations with Magnet status, there were no significant differences in FCC practice within individual and institutional characteristics. Hierarchical linear regression model indicated nurse empowerment was a strong predictor of FCC practice ([beta]= 0.31, R2 = 0.35, P < .001). There was only a weak, inverse association between CF and FCC practices (r =-0.199, P < .001).


Implication for Research and Practice: Further qualitative research will integrate these findings to understand the process by which neonatal nurses engage in FCC practices in the context of NICU setting. Future studies should examine facilitators and barriers of FCC practice in the NICU. Strategies (eg, policies and trainings) to increase nurse empowerment and support for FCC implementation should be developed and evaluated.


Article Content

Each year approximately 15 million infants worldwide are born prematurely and require admission to the neonatal intensive care unit (NICU).1 In 2018, the US NICU admission rate was 7.2 per 100 births.2 The complex and sophisticated environment of the NICU often excludes parents from the critical life-saving care of their infant.3 The hospitalization of a newborn in the NICU and prolonged hospital care may limit parental interactions between parent(s) and infant. Family-centered care (FCC) is a model of care that emphasizes families' unrestricted and active presence in the care of their infant.4 FCC encourages parents to take a central role in the infant's care, changing their status from "visitors" to "caregivers."5 When FCC is fully embraced in practice, the nurses' role transitions from an "active provider" to more of a "facilitator" for parents as they participate in the care process.6


NICU nurses are the cornerstone of implementing FCC. Despite this critical role, nurses may have difficulty integrating FCC components at the bedside due to barriers at the individual, unit, or organizational levels.7 Some of the nursing barriers identified in the NICU and pediatric settings include lack of sufficient training, time, communication skills, support within the healthcare system, threat of losing control over the patient's care, and fear of diminishing their expertise and authority.8 Caring for newborns, who are critically ill or dying, can be highly rewarding for NICU nurses; however, at the same time, this care may also be emotionally overwhelming or even traumatizing. These nurses are at risk for developing compassion fatigue (CF) due to the routine exposure to distressing aspects of infant illness or death, including the families' emotional responses.9 Research has shown nurses who suffer from CF tend to become overinvolved with their patients' care.10 Those nurses may develop involuntarily strong emotional bonds toward their patients, with beliefs of being the preferred provider over the parents.10,11 This overinvolvement in infant care may contribute to conflicts of power and control between nurses and parents.


The concepts of power and empowerment are interwoven. Power refers to a belief in personal self-efficacy, or more broadly, authority. In contrast, empowerment means the ability to effectively motivate and mobilize yourself and others (eg, the care team) to achieve positive outcomes.12 When empowered nurses motivate themselves instead of parents, they may disturb the balance in the nurse-parent relationships.


Most studies on FCC in the NICU focus on the parents' experiences13 or on the relationship between NICU nurses and parents.14 Few studies have examined the nurses' understanding of FCC and how to integrate it into practice. As a result, knowledge is lacking about NICU factors affecting FCC implementation. Additionally, while FCC may be considered a gold standard in NICU care, research has demonstrated it is not consistently practiced in this setting.15 Understanding the relationship between CF, empowerment, and FCC practices among NICU nurses has not yet been explored. By identifying the factors that influence NICU nurses' practices of FCC, the quality of infant and family care may ultimately be improved. Therefore, this study aimed to determine the relationships between nurse empowerment, CF, and FCC practices among NICU nurses while controlling for individual and institutional characteristics.



Griffin5 describes FCC in the NICU setting as unrestricted parental presence, parental involvement in caregiving, and healthcare professionals' open and honest communication with parents. Parental presence is exemplified by not only physical bedside presence but also interactive parent engagement with their newborn, such as talking with their infants, reading books, telling stories, and singing lullabies. Parental involvement in caregiving is described as providing physical care, such as skin-to-skin contact, touching, holding, breastfeeding, infant massage, and diaper changing. Finally, healthcare professionals' open and honest communication with parents involves parents' active participation in the decision-making process related to their infants' care, such as parental engagement in the decision-making process when the infant is weaned from mechanical ventilation.5


Research has demonstrated that FCC has a positive impact on infants, parents, and nurses. Benefits of FCC for infants include higher oxygen saturation,16 better neurobehavioral development at discharge,17 improvement in overall well-being,18 higher newborn weight gain,19 enhanced parent-infant attachment,20 shorter hospital stays,21 and reduced readmission rates.22 Practices of FCC provide benefits for parents such as a reduction in stress and anxiety,19,20 greater confidence and competence in parenting post-discharge,20 and higher parent-infant bonding.19 While the benefits of FCC for parents and infants are well studied, research on the effects of FCC for nurses is limited. From the studies that have been performed, the impact of FCC on nurses includes improved staff satisfaction and experiencing feelings of reward and accomplishment, as the parents become more competent and confident in their infant's care.23 Finally, although some nurses believe parental participation results in a greater workload,24 others believe parental involvement facilitates their FCC practice, whereby reducing their efforts.25


FCC has not been found to be consistently and effectively implemented into practice, as it depends on the perceptions and responses of healthcare providers, the critical nature of the infant receiving care, and the parents' desire for involvement.26,27 Studies have shown that although NICU nurses have knowledge about the principles and benefits underlying FCC and positive beliefs about encouragement toward parents, they report it challenging to implement into practice largely over concerns about losing power, control, and responsibilities.8 Nurses have also reported confusion between the involvement of parents in infant care and their own professional responsibilities.28 Finally, despite nurses being willing to support parents in their parenting roles, some have less desire to support parents in the technical aspects of care due to the potential legal implications.5,7,29


What This Study Adds


* Of the 21 individual and institutional characteristics investigated, only Magnet status and use of web cameras were associated with higher FCC practices.


* When controlling for other factors, nurse empowerment is strongly associated with FCC practices.


* Compassion fatigue was only weakly associated with diminished FCC practices.



To understand the factors associated with implementing FCC, the framework of the complex adaptive system (CAS) guides this study. The theory has 3 components: nonlinearity, unpredictability, and self-organization. Cilliers30 describes complex systems as having many agents that interact locally and nonlinearly through feedback loops causing unpredictable outcomes. CAS agents have individual relative freedom to direct their own behavior.31 Depending on the context, an agent may be a biologic cell, a person, or an organization. Agents are independent and often have different roles. They come into the system with different knowledge, power, and experience and create a relationship between other agents.31 Although there are some power centers, there is no single point of control. The complex system follows simple rules that are not controlled by a central authority. A system in CAS theory has recurrent interactions between agents via both positive (stimulating) and negative (inhibiting) feedback loops.30 The process of information return from a feedback loop continues until the system achieves its purpose.32


The CAS has been adapted to the NICU setting by D'Agata and McGrath.33 The NICU setting is described as complex because of "many working parts connected in some way," adaptive because it is "constantly changing," and as a system, due to the "set of elements that operate in relation to one another."33(p246) The NICU has a "nested structure" made up of different agents: physicians, NICU nurses, ill infants, and parents. Based on the work of D'Agata and McGrath,33 the behavior in the NICU system is often inherently unpredictable and nonlinear as agents interact. The roles and expectations alter among each agent and they interact with others in different ways, resulting in essential feedback loops.33


The implementation of FCC in the NICU is multifaceted because of the combination of different human behaviors, their interactions, and relationships. Studying NICU nurses' practices of FCC through the lens of a CAS helps to understand how and why NICU nurses implement or do not implement FCC practices. The agents embedded within family-centered infant care bring their own history, knowledge, values, and power differences.



Empowerment is associated with leadership; the construct is described as an active process where a person "feel[s] able to shape his/her work role and context."12(p1444) Spreitzer12 defines psychological empowerment as a motivational construct with 4 key components: meaning, competence, self-determination, and impact. Meaning refers to the individual's perception of the work environment based upon the individual's own ideas, beliefs, and behaviors. Competence is the individual's beliefs about their work capabilities and performance. Self-determination is the individual's perceived autonomy in the initiation and continuation of work behaviors. Impact is the degree of an individual's perceived ability to influence strategic, administrative, and operating outcomes at work.


Research has shown that empowered nurses are more confident in their abilities and have greater control over their work.34 However, in the NICU, a power struggle may exist between nurses and parents concerning parental involvement in infant care.35 Parents are often unprepared to parent a premature or critically ill newborn. However, nurses have the capacity and knowledge to care for these infants in the NICU setting. A NICU admission can result in an imbalance of power contributing to feelings of dependency,36 when parents place their newborn in the hands of the nurse. Nurses may also perceive a threat to the safety of infants when they allow parental involvement in the infant's care.23 In theory, empowered nurses who take too much control over the infant's care may be less likely to engage in FCC practice. This paradoxical relationship between empowerment and FCC has yet to be investigated.



As a consequence of working with critically ill infants who often suffer from life-threatening conditions and many succumb to their illness, some NICU nurses may experience secondary trauma. Since NICU nurses are regularly exposed to ill patients and families in distress, they are at high risk for developing CF.9Compassion fatigue is 1 of 3 components of Stamm's37 Professional Quality of Life, which is defined as feeling physically, emotionally, and spiritually depleted when caring for patients. CF focuses on the experiences of individuals who work with traumatized people.38 CF can negatively affect the nurse's quality of life, which can ultimately impact their caregiver role.39 Nurses who suffer from CF may tend to become overinvolved in their patient's care,10 creating an emotional bond with them.11 This overinvolvement coupled with existing power struggles between parents and nurses35 may further impact their implementation of FCC.




A mixed-methods study was conducted to understand facilitators and barriers of practicing FCC. This article reports the quantitative findings of a cross-sectional, descriptive correlational survey that examined the relationships between FCC practices, nurse empowerment, and CF.


Setting and Participants

The target population for this study was registered nurses practicing in the NICU at the bedside. Inclusion criteria were (1) being a registered nurse actively working in the NICU and (2) having at least 6 months of NICU experience. Nurses who do not provide bedside care to patients (eg, administrators) or who were not currently practicing were excluded. A convenience sampling strategy was used for recruiting participants from the National Association of Neonatal Nurses (NANN) and social media (3 Facebook NICU groups). A power analysis was conducted to estimate the required sample size using an online power calculator with the following parameters: anticipated medium effect size (f2) of 0.15, statistical power of 0.8, desired probability level of .05, and 11 predictors.40 The final estimated sample size was 144, which included an extra 10% to account for potential attrition.



The participants completed an online survey that included a demographic form and 3 instruments. Due to potential changes in practice resulting from the pandemic, participants were asked to reflect upon their pre-COVID practice and respond accordingly. The Family-Centered Care Questionnaire-Revised (FCCQ-R)41 was used to assess healthcare professionals' perceptions and practices about FCC. The instrument includes 2 different subscales using the same 45 items: current subscale and necessary subscale. The current subscale asks participants to indicate which activities they perceive to be present in their current nursing practice; the necessary subscale asks subjects' perception of how necessary each of the items is for FCC. This study used only the current subscale. The responses to each item of the self-administered tool are rated on a 5-point Likert-scale, ranging from "1 = strongly disagree" to "5 = strongly agree." The total possible score for the current subscale ranges between 45 and 225, with higher scores indicating higher engagement in FCC practice. The current scale has demonstrated good internal consistency (Cronbach's [alpha]= 0.89) among pediatric nurses.41


The Psychological Empowerment Instrument was designed by Spreitzer12 to measure the use of power in the workplace. This is a self-administered 12-item questionnaire with 4 subscales: meaning, competence, self-determination, and impact. The responses are rated on a 7-point Likert-scale, ranging from "1 = very strongly disagree" to "7 = very strongly agree," with the total possible score ranging between 12 and 84. Higher scores indicate greater psychological empowerment in the workplace. This empowerment instrument has demonstrated good reliability (Cronbach's [alpha]= 0.72) among mid-level employees and managers from an industrial organization.12 Though not specifically in the NICU setting, the scale has been used with nurses.34,42,43


Finally, the Professional Quality of Life Scale (ProQOL) was revised by Stamm37 to measure healthcare providers' work-related positive and negative experiences. The scale is based on a theoretical framework that analyzes pathways of convergence between person environment (eg, nurse), client environment (eg, patient), and work environment (eg, hospital).37 This is a self-administered 30-item questionnaire that includes 3 subscales-compassion satisfaction, compassion fatigue, and burnout-each having 10 items. This study used only the compassion fatigue subscale of the ProQOL (v. 5). Compassion fatigue is identified as work-related secondary exposure to stressful events. The responses are rated on a 5-point Likert-scale, "1 = never" to "5 = very often." The possible score ranges between 10 and 50, with higher scores in CF indicating the respondent feels more overwhelmed with thoughts of their patients. The sum of scores 22 or less indicates low level of CF.37 The instrument's subscale has acceptable reliability among pediatric nurses (Cronbach's [alpha]= 0.81).39


Face validity and feasibility of the instruments were assessed with NICU nurses. These 4 volunteers completed the surveys in about 15 minutes and 3 seconds. According to their feedback, minor modifications were made to 33 FCCQ-R instrument items and 7 ProQOL compassion fatigue questionnaire items (eg, NICU-specific examples and terminology). The nurse empowerment measurement remained same.


Data Collection

The study protocol was reviewed and approved by the George Mason University Institutional Review Board and the NANN Research Ethics Committee. The online anonymous survey was administered between July and September 2020 using Qualtrics (Qualtrics, Provo, Utah), an online survey platform. Prior to participating, respondents were first screened for eligibility through survey items. Subsequently, an online consent form explained the study process, purpose, potential risks and benefits, protection of confidentiality and privacy, and right to participate or withdraw. Participants had an opportunity to be entered into a random drawing to win 1 of 4 electronic tablets (valued at $150 each).


Data Analysis

The data collected were analyzed using Statistical Package for the Social Sciences (SPSS) (IBM, Version 25). After data cleaning, missing data and outliers were examined. Of the 248 respondents who met eligibility criteria, 72 (29%) were excluded due to 15% or more missing survey items. Specifically, 21 participants did not answer any items while the remaining 51 respondents did not complete 1 or more of the following instruments: FCCQ-R (n = 48), empowerment (n = 48), CF (n = 49), or the demographics questionnaire (n = 2). No more than 9.1% of the remaining responses per item were missing and determined to be missing completely at random (Little's MCAR test: [chi]2 = 268.63, P = .267). These missing points were replaced with either the mean or mode, depending on the data type.44


Descriptive statistics were used to report sample characteristics. Bivariate analyses were performed to examine relationships between the independent variables and FCC using the independent t test, analysis of variance, and Pearson's r correlation coefficient. The data were assessed for assumptions of normality, linearity, and homogeneity and transformed as indicated.44 Hierarchical linear regression analysis was conducted to identify the variables that explain the most variance in FCC. To find the model of best fit, individual characteristics were first loaded in the model. Subsequently, institutional characteristics were added to the model, followed by empowerment, and finally CF. Individual and institutional characteristics were selected for multivariate analysis based on individual linear regression results with a P value .2 cut-off.45 For regression analysis, hospital type was recoded as a Magnet or non-Magnet status. A P value < .05 was considered significant.



Sample Characteristics

In total, 176 registered bedside neonatal nurses completed the online survey (68% completion rate based on 260 total initial responses; Figure 1). Table 1 provides an overview of the individual characteristics of the respondents. All but 11 respondents (6.3%) were employed within the United States, representing all 4 regions: Northeast (n = 25, 14.2%); Midwest (n = 50, 28.4%); South (n = 45, 25.6%); and West (n = 45, 25.6%). The sample was mainly female (n = 174, 98.8%), Caucasian/White (n = 143, 81.3%), non-Hispanic (n = 161, 91.5%), and married (n = 111, 63%) with having at least 1 child (n = 117, 66.5%). Participants' mean age was 42 years (SD = 12). Professionally, nurse respondents were mostly bachelor's prepared (n = 118, 67%), certified in a NICU specialty (n = 95, 54%), and members of a professional organization (n = 127, 72%). The respondents averaged 13 years of NICU experience (SD = 10.67), and many lacked specific FCC training (n = 91, 51.7%).

Figure 1 - Click to enlarge in new windowFIGURE 1. Final sample flow diagram.
Table 1 - Click to enlarge in new windowTABLE 1. Comparison of Family-Centered Care Based on Individual Characteristics (N = 176)

Table 2 shows an overview of the institutional characteristics of the respondents. Some of the institutions had earned Magnet status (n = 69, 39.2%). Half of the facilities had a traditional open-bay layout design (n = 87, 49.4%). The majority of the respondent's institutions allowed 24-hour parental access (n = 152, 86.4%) and sibling access (n = 153, 86.9%). More than half of the institutions (n = 101, 57.4%) do not have a web camera system available. However, a large number of the respondents' NICUs (n = 130, 73.9%) provide a private area for parent consultation; the majority of facilities also allow parental presence during rounds (n = 164, 93.2%) or shift report (n = 136, 77.3%). Less than half of the neonatal nurses (n = 83, 47.2%) believed their NICUs had adequate staff for FCC practice.

Table 2 - Click to enlarge in new windowTABLE 2. Comparison of Family-Centered Care Based on NICU Characteristics (N = 176)

Study Variables and Bivariate Analysis

All 3 study variable instruments demonstrated good internal consistency (FCC Cronbach's [alpha]= 0.94; nurse empowerment Cronbach's [alpha]= 0.86; CF Cronbach's [alpha]= 0.88). Distribution of the instrument scores for continuous variables is presented in Table 3. Among the sample, 117 (66.5%) neonatal nurses demonstrated low CF level. As Tables 1 and 2 demonstrate, there were no significant differences in mean FCC practice scores within individual and institutional characteristics except for organizational Magnet status. The relationship between FCC and continuous variables was investigated using Pearson product-moment correlation coefficient (Table 3). Figure 2 indicates there was a medium, positive association between FCC and empowerment (r = 0.37, 95% confidence interval, CI 0.208, 0.505], P < .001) and a small, negative correlation between FCC and CF (r =-0.20, 95% CI [-0.368, 0.010], P < .001). No correlation was found between FCC and age or years of NICU experience.

Table 3 - Click to enlarge in new windowTABLE 3. Bivariate Analysis of Continuous Sample Characteristics and Study Variables (N=176)
Figure 2 - Click to enlarge in new windowFIGURE 2. Scatterplot of family-centered care-empowerment and compassion fatigue.

Hierarchical Regression Analysis

Hierarchical multiple regression techniques were conducted to assess whether nurse empowerment and CF predicted variation in FCC practices, after controlling for the influence of individual and institutional characteristics. Assumptions of normality, linearity, multicollinearity, and homoscedasticity were tested and determined to be not in violation with one exception. CF was found to be positively skewed and transformed by log10, with subsequent analysis conducted with both the original and transformed variable. Results of the independent linear regression analyses identified 2 individual characteristics (NICU certification and FCC training) and 7 institutional characteristics (Magnet status, NICU layout, web camera, parent present during rounds, perceived adequate staff, private area for consultation, and parental access), which met our criteria (P < .2). When loaded in the multivariable regression (Table 4), the amount of variance in FCC explained increased from 10.5% (model 1) to 27.7% (model 2), with the addition of institutional factors (R2 change = 0.172, F = 5.65, P < .001). Only the perception of adequate staff to perform FCC (P < .001) and the availability of a private area for consultation (P < .002) were significant in model 2. After empowerment was added in model 3, the total variance in FCC explained increased to 35.1% (R2 change = 0.73, F = 18.62, P < .001). In this model the availability of a web camera was also significantly associated with an increase in FCC practice (B = 7.79, P = .03). Although CF was loaded in model 4 using both original and transformed (data not shown) versions of the variable, there was no significant increase in variance explained (R2 change = 0.002, F = 0.46, P = .497). Thus, final model of best fit is model 3.

Table 4 - Click to enlarge in new windowTABLE 4. Hierarchical Multiple Regression Analysis Results (N=176)


Although a vast amount of literature exists, the ongoing question of why FCC is not well integrated into nursing care of infants in the NICU setting remains perplexing. Our study took a first step in identifying facilitators and barriers to FCC practice among neonatal nurses. Specifically, we examined individual and institutional factors associated with FCC practice and its relationship with CF and nurse empowerment. Our results revealed both new and conflicting findings to previously published research.


We found no significant variation in FCC practices based on the following individual characteristics: gender, age, race, ethnicity, marital status, being a parent/guardian of a child, nursing education, years of NICU experience, having a NICU certification, membership in a professional organization, and receiving FCC training. These findings conflict with other studies in pediatric settings, which found more educated nurses engaged in FCC practices.28,46,47 Bachelor's prepared education provides holistic care and more engagement in evidence-based practice, and it also improves critical thinking and therapeutic communication skills. Although one can be licensed as an RN with an associate's degree, some organizations or facilities prefer the minimum of a baccalaureate degree to practice in the NICU.48 Our sample may reflect the stricter requirement; more respondents had a bachelor's (67%) than an associate/diploma (10.8%) preparation. We found no variation in FCC practice based upon education.


As noted in the literature,28,47,49 and we speculated would be true, nurses with more years and NICU experience would strongly support FCC practices. Our findings however did not reflect this theory. Instead, our findings confirmed those of Coyne and colleagues,27 who found no significant difference in FCC practice in the NICU based on the nurses' age, years of experience, or education. Matziou and colleagues46 did find pediatric nurses aged 20 to 30 years or with less than 10 years of nursing experience practiced more FCC. Their results may be explained by more recent graduation from nursing programs.


Our results indicated NICU nurses' family background (ie, marital and parental status) was not associated with FCC practice, which is consistent with other research.29 However, our finding conflicts with a pediatric study in which married nurses with children engaged in significantly higher FCC practices.46


We found no significant differences in FCC practice based on several institutional characteristics, including NICU layout, parental access, sibling access, private area for parent consultation, parental presence during rounds or shift reports, and perceived adequate staff to perform FCC. Limited studies have examined the relationship between institutional characteristics and FCC practices in the NICU. Among them, nurses in the study by Asai49 suggested 24 hours of unlimited parental access and sibling visiting policies may support FCC model. Tandberg and colleagues50 found single patient rooms improved nurses' and parents' perception of parent closeness. We noted a significant difference in FCC practice based on type of hospitals, indicating Magnet hospitals were more likely to practice FCC in the NICU setting compared with academic, community, or other types of hospitals. Magnet status empowers nurses to be a part of the decision-making process about patient care and nursing practice. Magnet hospitals value nursing's input by providing some control over the technologies, processes, and decisions that would affect the nurses' clinical practice.51 Through Magnet status, the hospital trusts nurses and encourage them to be involved in decision-making. Additionally, the availability of a web camera was associated with greater FCC practice when controlling for empowerment and other individual and institutional factors. It is possible that the use of a web camera strengthens the loop of trust between parents and nurses, contributing to stronger FCC practice. Web cameras may allow nurses to pivot and develop trust with parents and vice versa. Thus, the technology creates a better environment to practice FCC in the NICU setting.


This study was significant in that no known research had yet explored empowerment and CF as predictors of NICU nurses' FCC practices. Our findings indicate that nurse empowerment was a strong predictor of FCC practices, which is consistent with NICU nurses being more patient-oriented and goal-conscious.34 Some studies have shown empowered nurses are more positive toward their work, more satisfied with their job,34 and more likely to apply their skills and improve their practice.42 Our findings did not support the proposition that empowered nurses may be less likely to engage in FCC practice. It had been theorized that empowered nurses may take too much control in infant care, thereby altering the balance in the nurse-parent relationship.10 However, our results suggest more empowered nurses are more likely to practice FCC in the NICU setting, perhaps due to increased confidence in their own abilities.


Alternatively, CF had only a weak, inverse association with NICU nurses' FCC practice. For some NICU nurses, the secondary trauma experienced from caring for suffering infants and managing the emotional burdens of their parents may contribute to CF.9 As a result, research has suggested nurses may develop involuntarily strong emotional bonds toward their infant patients with beliefs of being the preferred provider over the parents.10,11 Therefore, we theorized NICU nurses' conscious or unconscious overinvolvement in infant patient care may prevent their engagement in FCC. Our lack of significant findings may be explained by the primarily low CF of the respondents (66.5%). Given that only 35% of the variance was explained in the model of best fit (model 3), other factors may be contribution to variations in FCC practice.



As with many studies being conducted during the COVID-19 pandemic, our results may have been influenced by potential changes in practice resulting from added safety precautions. Participants in our study were guided to consider their responses to reflect their pre-COVID environment. However, response bias was likely unavoidable. The length of the survey may have contributed to the number of incomplete responses.


Our study used a cross-sectional design, which limits the ability to infer cause-and-effect relationships among the variables. Also, this design limits the prediction of how scores on the variables may change over time. Additionally, convenience sampling may have contributed to self-selection bias. NICU nurses who were members of NANN may have been more committed to practicing FCC and more likely to participate in the study. Because the sampling plan involved nationwide data collection, we were unable to control institutional factors such as policies and procedures in FCC practices. Finally, although existing research on the relationship between gender and FCC is conflicting,29,46 our limited number of male respondents (n = 2) likely contributed to the lack of significant findings.


Implications for Practice and Future Research

Our results indicate empowering nurses, encouraging Magnet status, and providing web cameras may all contribute to an increase in FCC practice within the NICU setting. Organizations and administrators should provide necessary resources to support empowerment through mentorship programs and trainings to enhance nurses' communication and leadership skills.43 Additionally, administrators should advocate for nurses to become evidence-based practice leaders and positive agents for change.48 To increase empowerment, neonatal nurses should consider collaborating on organizational committees and engage in leadership opportunities at the institutional and department levels. FCC practice may also be supported by the organization through global initiatives, such pursuing Magnet recognition and the implementation of web cameras, to facilitate parent engagement. Finally, ongoing education in FCC can be facilitated through workshops or training provided by state and national nursing associations.


Our qualitative research will integrate these quantitative findings to understand the process by which neonatal nurses engage in FCC practices in the context of the NICU setting. Our goal is to gain a deeper understanding of barriers and facilitators to NICU nurses engaging in FCC practice. Additional studies are needed to examine FCC from other perspectives (eg, physicians, parents, and administrators). This study is important because it shows an association between FCC practices and nurse empowerment, Magnet status, and use of web cameras. Finally, further research is needed to evaluate interventions targeting FCC practices and empowerment skills.



We would like to thank the many participants who volunteered for this study. This project was awarded by the National Association of Neonatal Nurses and Sigma Theta Tau International, Epsilon Zeta Chapter. The opinions, findings, and conclusions or recommendations expressed in this publication are those of the authors and do not necessarily reflect those of the associations.




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For more than 142 additional nursing continuing professional development activities related to Neonatal topics, go to


compassion fatigue; empowerment; family-centered care; Magnet status; NICU; NICU nurses