1. Griffin, Terry MS, APN, NNP-BC


Parents are important partners in the neonatal intensive care unit, collaborating with staff in caregiving and decision making for their infants. These essential and mutually beneficial partnerships between families and staff are the cornerstone of family-centered care and require that parents are welcomed to be with their baby at any time. This concept is not new and, yet, many neonatal intensive care units continue to have "visitation" policies that restrict parent's access to their infants, failing to recognize parents as partners. Changing the "visitation" policy is part of a welcoming approach in the context of family-centered care. Neonatal intensive care unit nurses may be accustomed to a more strict policy, needing communication tools and strategies to collaborate with parents and implement a family-centered "visitation" or welcoming policy.


Article Content

The Institute for Patient- and Family-Centered Care defines such care as "an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families," a redefining of relationships in healthcare.1 In the neonatal intensive care unit (NICU), parents typically are the baby's family. In adult care settings, a competent adult patient would define his "family." For the purpose of this article, the baby's parents are considered the family.


Within the context of family-centered care (FCC), parents are not seen as "visitors" in the NICU. Rather, they are our allies for safe and quality infant care.1-5 Parents are and should be engaged as partners in caregiving, with the goal that they will become primary and expert caregivers of their baby.6 Many of us continue to work in organizations with restrictive "visitation" policies that do not fully support families in this way. Policies are a necessary part of the NICU and some rules are absolutely required, including methods for identifying parents of a baby. Other aspects of the "visitation" policy would better serve the individual needs of the baby and parents if they provided guidance to generally support parent presence in the NICU and help make decisions to meet individual family needs. The purpose of this article was to compare and contrast components of a traditional "visitation" policy (TVP) and a family-centered "visitation" policy (FCP). Basic strategies for collaborating and communicating with parents to implement an FCP and a sample family-centered policy are provided (see Figure 1).

Figure 1 - Click to enlarge in new windowFigure 1. Sample family-centered policy. NICU indicates neonatal intensive care unit.


There are 4 core concepts of FCC that underpin the partnering relationships with families: (1) families are treated with respect and dignity; (2) information is shared in ways that are both affirming and useful; (3) families are encouraged to participate in care; and (4) staff collaborate with parents in policy and program development, implementation, and evaluation; in healthcare facility design; and in professional education, as well as in the delivery of care.1 The underlying premise of FCC is that care and outcomes can be improved when we partner with families in the NICU.2,4,7 Family-centered care has become the gold standard in healthcare.8 Restrictive "visitation" policies can inhibit the concept of parents as partners in care and result in these FCC concepts not being supported.



To engage parents/families as partners in the care of their newborns, "visitation" policies can be written using language that supports and welcomes families.9 An FCP eliminates the word "visitor." When we label parents/families as "visitors," we suggest that they are expendable and inconsequential to the care and decision making for their infants. An FCP title could be changed to "partners in care" rather than "visitation."


Other language typically used in a TVP may include "allow" and "require." This is not the language of partnership and collaboration but, rather, the language of power. Traditional "visitation" policies may limit the parents/families access to their infants throughout the day. Such restrictive policies do not respect the family individual needs, sharing of information during rounds and report, nor offer them the opportunity to fully collaborate and participate in their infants' care. Parents are our partners because we share common goals.10 Both staff and families want their babies to receive safe and quality care in a healing environment that will lead to the best outcomes. Rather than "allowing" parents/families to be with their babies, we should "welcome" them as our partners in achieving these goals.


Typically, "visitation" policies address the following components: (1) who can "visit"; (2) how many people can "visit" at a time; and (3) when they can "visit." These components are addressed in the following sections. Sample communication strategies are offered for nurses when a policy consists of guidelines rather than rules.



While traditional policies specify who can come to the NICU, a family-centered policy acknowledges that parents know best who can provide them the support needed during this time.11 In contrast, a TVP will decide for the parents who will be welcomed into the NICU. The TVP may state that only parents and grandparents or immediate family members are "allowed" to "visit" the infant. Such rules are not respectful of parents needs. To be culturally sensitive and supportive, we must acknowledge that parents can decide who is important to them in this situation. Family must be defined by the parents and not by the unit policy. The American Academy of Family Physicians offers the following definition: "The family is a group of individuals with a continuing legal, genetic and/or emotional relationship."12 Therefore, parents should be able to identify who is most important to them.


An FCP would state: "Family and friends are welcome when they are accompanied by the parents."


Suggestions for staff

We do not have strict rules about who can come with you to see your baby. Only you know who is most important to you. Just like you, we want to keep him safe from infection, so we need to be certain that your family or friends are not ill. If you need help from us to limit the number of people coming here or worry that someone is ill, let us know. We want to work together to keep your baby safe from illness and over-stimulation. We can be the "bad guy" and enforce limits for you.



Often, traditional policies regarding "visitation" limit sibling presence on the basis of age or siblings may be entirely restricted from the NICU. These restrictions are based, in part, on concerns about communicable disease. Family-centered care does not mean that we do not protect babies from infection. It means that we partner with families to meet their needs while protecting babies. Our partnership is committed to keeping babies safe and improving outcomes.


Even when siblings are screened for communicable diseases and completion of immunizations, there may still be limits on ages that are welcomed to the NICU. While a 17-month-old cannot fully comprehend that this baby is their new baby brother or sister, it can be important for the parents to have their entire family together. Sadly, for some families, this may be their only opportunity to have all of their children together. When welcoming anyone, including siblings to the baby's bedside, we must remember that this is a baby's "sick bedroom" and with parents we must create and maintain a healing environment. While it may be developmentally inappropriate to have the siblings at the bedside for lengthy periods of time, it can be equally important to welcome siblings for brief periods of time. Siblings can be successfully welcomed to the NICU.13


Suggestions for staff

We know you have a 2-year-old and a 6-year-old. If you want them to come and see the baby, we can help you prepare them. Given their ages, we know that they cannot stay for long, but they are welcome to come for a couple of minutes to meet/see their new brother/sister. We can take a picture of all of you if you would like.


If the parents bring a 2-year-old into the NICU and that child is breaking down: "Mr. Smith, it seems like this is too much for Billy. Since we all want a healing environment for your baby, let me help you so you can take him outside."



Often, traditional visitation policies limit the number of people at the bedside. At times, it is absolutely necessary to limit the number of people at the infant's bedside. It is not possible to provide safe care if the nurse is unable to readily gain access to the equipment and the patient. This is especially true in an open bay unit with limited space. However, even in single family rooms, the acuity of the infant and the amount of equipment may prohibit large number of family and friends at the bedside.


There are times when parents desire a greater number of family and/or friends at the bedside. Examples include withdrawal of support, a baptism, or other religious ceremony. At times, there may be family from out of town, and, if care is not disrupted, welcoming both aunt and uncle or grandparents with the parents at the bedside eases stress for the family. Consider how many times we have "allowed" just 1 additional family member or friend to the bedside requiring either the mother or the father to leave to accommodate another person to be present. If the unit is quiet and the baby is stable at the moment, we can welcome more than the typical "2 at a time" to the bedside. This provides families a chance to be a complete rather than a divided family. At the very least, the parents should never be expected to leave the baby's bedside so that others may be present.


An FCP would state: "The number of family and friends welcomed at the bedside is determined by the unit, baby and family needs and negotiated with the family."


Suggestions for staff

I see that you have several family members/friends with you. At this time, it is quiet and you are welcome to bring everyone to the bedside for a little while. When we need more access to the baby or if it gets busier, then we will need everyone but you and his dad to step out for a while. This is important, because just like you, we want his care to be safe.


While we don't have a rule about the number of family and friends we welcome at your baby's bedside, we want to work with you to make sure the care we give to your baby and the other babies is safe. So, you will see that the number of people we can have with you will vary.



Although many unit policies offer 24/7 "visitation," in a TVP, parents may be excluded from the unit at certain times. These times may include (a) admission; (b) resuscitation; (c) procedures; (d) interdisciplinary rounds; and (e) nurse change of shift report. In an open bay unit, parents may be excluded for other patients' admissions, procedures, or emergencies. If parents are our partners, they are our partners 24/7, not 24 hours minus all of these exclusions.9,14


Parents' desire to care for their infants must be respected and demand the development of a collaborative relationship with the nurses and other staff members.15 Their caregiving may be interrupted when we ask them to leave.16 When staff members ask families to leave, it is often because we feel uncomfortable with their presence. Many nurses have been educated and practiced with policies limiting families at the bedside. Welcoming them at any time can be a new and unfamiliar concept. It is important for healthcare professionals in the NICU to explore feelings and concerns when implementing family-centered policies. Staff and family advisory leaders can help facilitate such discussions. Visiting and learning from units that have operationalized such policies can be helpful in providing information and addressing concerns.


Parent participation in rounds and report is important for safe care and increases satisfaction among both professional staff and parents.4,17-22 Rounds and report are times when information is shared and plans are made. Parents, as part of the team, want and need to know the plan of care, to have their questions answered, and contribute their observations about their baby's condition during these processes. Parents are historians and can support continuity of care when medical and nursing staff rotate.


Suggestions for staff

In interdisciplinary rounds, with large groups, staff can be introduced generally such as, "This is the team of people helping you care for your baby." Specific people can be introduced as needed.


Let's ask our pharmacist, Beth, that question.


You know Dr. Jones. She is going to tell your baby's story. If something seems wrong or missing, please let us know.


This is Sue, she will be Zoe's nurse tonight. She has worked here a long time and will take great care of her. We are going to give report now. Please let us know if something doesn't sound right or is missing.


Mrs. Smith, that is a great question. Let Sue and me check all of these medications so we don't make a mistake and then we can answer that for you.


At the end of rounds or report: "Are there any worries or concerns you want to share?"


When parents need/want more time than we are able to provide:


Mrs. Smith, that is a great question, but there is not a simple answer. It will take more time than we have right now, and I want to offer you enough time. Can I come back in 30 minutes? Then, we can sit together and answer your questions.


When babies are admitted or undergoing a procedure, traditionally, parents have been excluded from the NICU. Yet, their ability and willingness to comfort the baby can be beneficial.23,24 For example, when an infant is admitted and a peripheral intravenous catheter inserted, the mother or father can offer the baby nonpharmacologic comfort measures. If a procedure is occurring in the unit that requires staff to wear hats and masks, rather than requiring parents to leave, they can don hats and masks as well. When umbilical catheters are inserted, the parent can sit at the bedside and the medical or nursing staff can explain what is happening and why. The opportunity to be near the baby during such a procedure can have unexpected meaning to parents. One father, sitting near the bedside, remarked during his son's umbilical catheter insertion, "I guess this is the closest I will ever get to cutting the cord." Families should be offered the opportunity to be present during their baby's resuscitation, with an appropriate staff member designated as their support person during the process.25,26 While staff can have conflicting views about family presence and should have the opportunity for professional development and preparation,25,27,28 these practices are recommended.5,26,29


In an open bay design, parents have been excluded during admission, procedures, and emergencies with babies other than their own. Rather than requiring parents to leave, privacy screens can be used to separate the patients and other families. In fact, parents often are aware of another baby's emergency and may have an increased desire to stay with their baby. A father was engaged in skin-to-skin care when another baby's support was being withdrawn in an open NICU. It was quite clear to him that something serious was happening behind the privacy screen.


Staff suggestion

"Mr. Smith, I know you know something sad is happening. Are you okay or do you want help putting him back to bed?" The father gripped more tightly to his son. "No, I am okay. I don't want to leave him." The next day the father thanked us for not making him leave. He told us he knew death was in the room, and he wanted to stay, hold tightly onto his son, and protect him.


An FCP will acknowledge and state: "Parents are our partners in caregiving and decision making; they are welcome to be with their babies 24 hours per day."


Suggestions for staff

We do not have visiting hours because you are not a visitor. You are her parents and our partners in helping her get better. There are things she needs that only we can give and there are things that only you can give. We are going to work together to help her get better.



To embrace FCC, educational and supportive strategies are important for the staff.14,28,30 The ability to practice FCC may be challenging for nurses.7,16,31,32 Many nurses have practiced in units with restrictive traditional policies and may lack the tools or confidence to welcome families as partners. All NICU nurses want to give the best care. While changes in technical care have been embraced, adopting a philosophy of FCC may be seen as less desirable by some staff members. Yet, partnerships with families can improve care, outcomes, and satisfaction. The equipment, medications, and tests we use have evolved over the decades, and we welcome new technology that improves outcomes. We must also welcome a different and improved way of relating with parents/families. Parents are our partners in providing care for their babies; they are not visitors.


To successfully implement an FCP, the same successful strategies that are used when a new pump is introduced in the unit can be used. Typically, these strategies include a definition and understanding of the benefits of the new equipment, in-services, and workshops, identified superusers or champions, resources, and competencies. There is an evaluation component where staff members identify challenges they have faced using the equipment so that the issues can be addressed. There is ongoing support for the staff until everyone is competently using the new pump. The same process can be used to implement a new policy that is family centered.


Some nurses will state that welcoming parents as partners cannot be done; however, it is being successfully accomplished in other units.8,16 When we consider liberalizing the presence and number of family and friends welcomed at the beside, nurses will rightfully express concern about safety and confidentiality. Nurses' concerns about their own and parent comfort during procedures and emergencies must also be addressed. These are important concerns that should not deter us from doing what is right for the parents and their NICU babies. Rather than approaching an FCP as impossible, we must ask-"How can this be achieved?"


Family advisors are integral in facilitating change to achieving FCC.33 Formal family advisors can collaborate with staff to move from a traditional to family-centered policy framework. If a formal family advisory council has not yet been created, parents can be informally asked for their suggestions and feedback. Discharge surveys and leader rounds can solicit specific information about the ability of a current policy to meet the family needs. A parent panel can share with the nursing staff what worked well with the current policy and what suggestions they have for improvement.


When implementing an FCP, parents can help develop information suited for other parents to explain the policy, define rounds and report and how parents can contribute, and provide a list of signs and symptoms of illness that would limit one's presence in the NICU. Parents can help nurses develop communication skills for addressing different situations that might arise. Nurses can benefit from learning communication strategies to partner with families to achieve family-centered policies and care.



While guidelines can be intimidating and some staff members may prefer more strict rules, we know that nurses "break" rules to meet the needs of individual families, creating conflict among staff and families. Families may then prefer the "nice" nurse who "lets" them in to see their baby, and other families may notice this preferential treatment. Nurses wish do to what is right for the baby and family and can learn communication and negotiation skills to successfully implement family-centered policies and care. Indeed, issues will arise with the implementation of an FCP but issues already arise with a TVP. Family-centered care is not simply a change to a family-centered policy, but it is a first step. When we treat parents as visitors, we cannot fully achieve the principles of FCC. Families have the right to be with their babies, and the babies have the right to be with their family.


The time has come to eliminate the traditional visitation policy in the NICU.




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NICU; parents; partnership; visitation