Moen A, Tandberg BS, Mader S, Ludes M, Sizun J, White R
Click on the image to read the standard in brief.
Target group
Infants, parents, and families
User group
Healthcare professionals, neonatal units, hospitals, health services, and other relevant stakeholders
Statement of standard
Neonatal care is optimised by utilising key design elements to promote the family as primary care givers throughout the stay.
Rationale
The design of the NICU may modulate significantly both short-term and long-term outcomes of neonatal care. (1–6) Infant- and family-centred developmental care (7,8) may be achieved independently of NICU design, but the health benefits of daily parent participation, interaction, and skin-to skin care are significantly improved if the environmental design allows privacy and protects from visual and auditory stress. (4,9–11) Facilitating unrestricted parent-infant closeness and skin-to-skin contact represent an underestimated opportunity for improving outcomes for infants. Benefits of Infant- and family-centred developmental care include reduced pain and stress (10,12,13), reduced sepsis (1,2,4,14), improved cardiovascular stability (1,2,15) and sleep (16,17), together with improved exclusive express (1,4,16,18), improved parental confidence, interaction and bonding (3,5,19,20), which lead to decreased length of stay(14) and readmission rates (14) and improved neurodevelopmental outcomes. (5,21–24)
The United Nations Convention on the Rights of the Child states that “The child … shall have the right from birth to … be cared for by his or her parents” (Article 7), and that “Parties shall ensure that a child shall not be separated from his or her parents against their will” (Article 9).(25)
The charter of the European Association for Children in Hospital states that “Children should have the right to have their parents or parent substitute with them at all times” (Article 2) and that “Accommodation should be offered to all parents and they should be helped and encouraged to stay” (Article 3).(29)
Improved parental presence, confidence and parent-infant interaction both pre- and post-discharge (4–8,20,27)
Increased skin-to-skin care (4,9,20)
Increased exclusive express (4,18),
Reduced rate of late-onset neonatal sepsis(4,14)
Long-term benefits
N/A
Components of the standard
Component
Grading of evidence
Indicator of meeting the standard
For parents and family
Parents and family are informed by healthcare professionals about NICU design and are part of the planning process for NICU design.
B (High quality)
Parent feedback, patient information sheet1, training documentation
Parents are guided by healthcare professionals about housekeeping rules, patient safety and hygiene, to facilitate their active role in the care of their infant.
B (Moderate quality)
Training documentation
For healthcare professionals and relevant stakeholders
A unit guideline on the organisation of care in developmentally supportive adapted NICU design is adhered to by all responsible stakeholders.
B (High quality)
Guideline
Training on the basic emotional, social and psychologic needs of patients, parents and siblings, and of the principles of Infant- and family-centred developmental care is attended by all responsible healthcare professionals and stakeholders before they are involved in the planning process for a new unit (see Infant- & family-centred developmental care).
B (High quality)
Training documentation
Healthcare professionals are part of the planning process for a NICU design.
B (High quality)
Audit report2
For neonatal unit and hospital
A unit guideline on the organisation of care in developmentally supportive adapted NICU design is available and regularly updated.
B (High quality)
Guideline
Training on the basic emotional, social and psychologic needs of patients, parents and siblings, and of the principles of Infant- and family-centred developmental care for everyone participating in the planning process is ensured (see Infant- & family-centred developmental care).
B (High quality)
Training documentation
Infant- and family-centred developmental care supportive areas are included during the design process.
B (Moderate quality)
Audit report2
Patient treatment area: each patient space has at least enough room for a comfortable chair and a hospital bed for parents next to the infant’s cot (minimal space 18 m²) (11,27)taking into account family-integrity and privacy; additionally separate parent sleeping facilities including a toilet and shower are sited within the neonatal unit (minimal space 10 m²).
A (Moderate quality)
Audit report2
Single occupancy areas: facilities for infants and caregivers are located in the same room (minimum space 24 m²) (2,8,9), and designed to take into account family-integrity and privacy. (11,27)
A (Moderate quality)
Audit report2
Clinical and monitoring working areas are located in close proximity to patient areas.
B (High quality)
Audit report2
Areas for eating and socialising for parents, private rooms for parent counselling, and staff rooms out of sight of parents are available on the unit.
B (High quality)
Parent feedback
Bereavement space and space to stay with the infant after death is provided within the design.
B (High quality)
Audit report2
The unit is built to comply with patient safety standards.
B (High quality)
Audit report2
For health service
A national guideline for NICU design incorporating the principles of Infant- and family-centred developmental care is available and regularly updated.
B (High quality)
Guideline
Parents and NICU healthcare professionals are involved in guideline development and planning processes.
B (High quality)
Guideline
1The indicator ‘patient information sheet’ is an example for written, detailed information, in which digital solutions are included, such as web-based systems, apps, brochures, information leaflets, and booklets.
2The indicator ‘audit report” can also be defined as a benchmarking report.
Where to go
Further development
Grading of evidence
For parents and family
Parents are present in single-family rooms. (3,4,6–9,11,27,28)
A (Moderate quality)
For healthcare professionals and relevant stakeholders
N/A
For neonatal unit
Provide single-family rooms and rooms adequately sized for care of multiple births. (6–9,11,27)
A (Moderate quality)
For hospital
Provide single-family rooms and rooms adequately sized for care of multiple births. (6–9,11,27)
Provide area for recovery for families; play areas for siblings, areas for parents to socialise.
A (Moderate quality)
For health service
Incorporate the single-family-room concept in national guidelines.
B (Moderate quality)
Getting started
Initial steps
For parents and family
Parents and family are verbally informed by healthcare professionals about parental involvement and infant closeness (the value of their presence and of skin-to-skin contact).
Parents and family are verbally informed by healthcare professionals about NICU design, housekeeping rules, patient safety and hygiene.
Parent representatives are encouraged to express parents’ needs regarding NICU design.
For healthcare professionals and relevant stakeholders
Attend training on basic emotional, social and psychologic needs of patients, parents and siblings, and of the principles of Infant- and family-centred developmental care to support future changes.
For neonatal unit and hospital
Building and/or rebuilding of NICUs, the Physical proximity between NICU and the obstetric department is a crucial element for early closeness (first 48 hours). (29)
Develop and implement a guideline on the organisation of care in developmentally supportive adapted NICU design.
Develop information material on NICU design, housekeeping rules, patient safety and hygiene for parents.
Involve all relevant stakeholders for the process of NICU design.
Provide space for a chair to support parent presence and skin-to-skin contact.
Guarantee privacy (e.g. by putting up a folding screen).
Provide adequate and secluded space for expressing of breast milk.
Identify areas in need of change and improvement and support implementation of and solutions for Infant- and family-centred developmental care.
For health service
Develop and implement a national guideline on the organisation of care in developmentally supportive adapted NICU design.
Develop a policy promoting Infant- and family-centred developmental care.
The standard focuses on the architectural and technical elements necessary to provide Infant- and family-centred developmental care at the cot side, consistent with the UN convention on the rights of the infant. Elements that are not specific to the implementation of these care principles are not covered in this standard but are extensively covered in the standard for neonatal intensive care units by White et al. (11)
The most difficult and challenging aspect of planning a NICU environment centred around the family and newborn infant is the change in culture and mind-set that has to take place among staff and administrators (30). This process has to start years before the physical planning. It requires leadership with dedication and in-depth understanding and knowledge of the combined scientific and humanistic approach necessary to create a caring environment combining principles of Infant- and family-centred developmental care with high quality intensive care. It also requires knowledge and a will to work by the principles of shared decision-making in healthcare.
Planning for a NICU environment facilitating optimal conditions for infant-parent contact and skin-to-skin care cannot be based only on scientific evidence, although evidence exists. A main source of information and input should come through visitation to units that has gone through the process of redesigning, and discussion with colleagues in these units about strengths and weaknesses of their design is a valuable source of information.
In the planning process, it should be acknowledged that there may be a conflict between the patient and families’ preferences and the preferences of the staff, building and technical department or the administration. Such conflicts should be handled with great caution with respect to the patients’ perspective, as the voice of the patient may otherwise be too weak to be heard. Free-speaking competent advocates for the patients’ interests should be appointed early in the planning process.
As part of the process, and before a full scale major re-design of a unit is taking place, leaders should be aware to the possibilities that minor physical changes or procedures in the existing unit allow introduction of new caring principles. An example may be to allow one or two parent beds to be placed beside the incubator or cot and then let the parents practice skin-to-skin care for as long as they wish with support from the staff. This will demonstrate to the staff that alternative ways of providing care is possible. It may also help the staff to see that most parents are very eager to participate and be present, and through participation are empowered to an extent that changes the traditional roles between staff and parents.
Although NICU healthcare professionals may be very experienced in what they are doing, it should be kept in mind that experience is most valid in the setting where it was gained. When Infant- and family-centred developmental care is introduced, the setting is fundamentally changed. Parents become the best observers of their infant, they represent the best continuity of care, and they learn skills in caring for their infant that may challenge the traditional roles of the staff. Parents are empowered and as their competence increase, they may appropriately question treatment decisions or procedures carried out by the staff.
The challenge of the staff adapting to empowered and protective parents, legitimately opposing treatment strategies or decisions from the staff, change the traditional balance in the NICU. It has also been shown to reduce diagnostic testing with all the pitfalls of over-diagnosis and overtreatment without putting the infant at risk of adversities.(26) Single family rooms and NICU design is no goal in itself; it is a tool to fulfil the rights of the infant to have its parents present without restrictions and to improve short- and long-term medical and neurobehavioral outcome. Good NICU design creates a protective physical environment for the vulnerable ill infant and encourage parents to take an active part in the care and medical treatment for their infant.
2. WHO Immediate KMC Study Group. Immediate “Kangaroo Mother Care” and Survival of Infants with Low Birth Weight. N Engl J Med. 2021 May 27;384(21):2028–38.
3. Lester BM, Hawes K, Abar B, Sullivan M, Miller R, Bigsby R, et al. Single-Family Room Care and Neurobehavioral and Medical Outcomes in Preterm Infants. PEDIATRICS. 2014 Oct 1;134(4):754–60.
4. van Veenendaal NR, Heideman WH, Limpens J, van der Lee JH, van Goudoever JB, van Kempen AAMW, et al. Hospitalising preterm infants in single family rooms versus open bay units: a systematic review and meta-analysis. Lancet Child Adolesc Health. 2019 Mar;3(3):147–57.
5. Lester BM, Salisbury AL, Hawes K, Dansereau LM, Bigsby R, Laptook A, et al. 18-Month Follow-Up of Infants Cared for in a Single-Family Room Neonatal Intensive Care Unit. J Pediatr. 2016 Oct;177:84–9.
6. Roué JM, Kuhn P, Lopez Maestro M, Maastrup RA, Mitanchez D, Westrup B, et al. Eight principles for patient-centred and family-centred care for newborns in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed. 2017 Jul;102(4):F364–8.
7. Browne JV, Jaeger CB, Kenner C, Gravens Consensus Committee on Infant and Family Centered Developmental Care. Executive summary: standards, competencies, and recommended best practices for infant- and family-centered developmental care in the intensive care unit. J Perinatol Off J Calif Perinat Assoc. 2020 Sep;40(Suppl 1):5–10.
8. Bergman NJ. Birth practices: Maternal‐neonate separation as a source of toxic stress. Birth Defects Res. 2019 Sep;111(15):1087–109.
9. van Veenendaal NR, van Kempen AAMW, Franck LS, O’Brien K, Limpens J, van der Lee JH, et al. Hospitalising preterm infants in single family rooms versus open bay units: A systematic review and meta-analysis of impact on parents. EClinicalMedicine. 2020 Jun 1;23:100388.
10. Lyngstad LT, Tandberg BS, Storm H, Ekeberg BL, Moen A. Does skin-to-skin contact reduce stress during diaper change in preterm infants? Early Hum Dev. 2014 Apr;90(4):169–72.
11. Altimier L, Barton SA, Bender J, Browne J, Harris D, Jaeger CB, et al. Recommended standards for newborn ICU design. J Perinatol Off J Calif Perinat Assoc. 2023 Dec;43(Suppl 1):2–16.
12. Johnston C, Campbell-Yeo M, Disher T, Benoit B, Fernandes A, Streiner D, et al. Skin-to-skin care for procedural pain in neonates. Cochrane Neonatal Group, editor. Cochrane Database Syst Rev [Internet]. 2017 Feb 16 [cited 2018 May 8]; Available from: http://doi.wiley.com/10.1002/14651858.CD008435.pub3
13. Campbell-Yeo M, MacNeil M, McCord H. Pain in Neonates: Perceptions and Current Practices. Crit Care Nurs Clin North Am. 2024 Jun;36(2):193–210.
14. Lehtonen L, Lee SK, Kusuda S, Lui K, Norman M, Bassler D, et al. Family Rooms in Neonatal Intensive Care Units and Neonatal Outcomes: An International Survey and Linked Cohort Study. J Pediatr. 2020 Nov;226:112-117.e4.
15. Bloch-Salisbury E, Zuzarte I, Indic P, Bednarek F, Paydarfar D. Kangaroo care: cardio-respiratory relationships between the infant and caregiver. Early Hum Dev. 2014 Dec;90(12):843–50.
16. Ludington-Hoe SM, Johnson MW, Morgan K, Lewis T, Gutman J, Wilson PD, et al. Neurophysiologic assessment of neonatal sleep organization: preliminary results of a randomized, controlled trial of skin contact with preterm infants. Pediatrics. 2006 May;117(5):e909-923.
17. Shahheidari M, Homer C. Impact of the design of neonatal intensive care units on neonates, staff, and families: a systematic literature review. J Perinat Neonatal Nurs. 2012 Sep;26(3):260–6; quiz 267–8.
18. Grundt H, Tandberg BS, Flacking R, Drageset J, Moen A. Associations Between Single-Family Room Care and Breastfeeding Rates in Preterm Infants. J Hum Lact Off J Int Lact Consult Assoc. 2021 Aug;37(3):593–602.
19. Axelin A, Feeley N, Campbell-Yeo M, Silnes Tandberg B, Szczapa T, Wielenga J, et al. Symptoms of depression in parents after discharge from NICU associated with family-centred care. J Adv Nurs. 2022 Jun;78(6):1676–87.
20. Tandberg BS, Flacking R, Markestad T, Grundt H, Moen A. Parent psychological wellbeing in a single-family room versus an open bay neonatal intensive care unit. Baud O, editor. PLOS ONE. 2019 Nov 5;14(11):e0224488.
21. Caskey M, Stephens B, Tucker R, Vohr B. Adult Talk in the NICU With Preterm Infants and Developmental Outcomes. PEDIATRICS. 2014 Mar 1;133(3):e578–84.
22. Caskey M, Stephens B, Tucker R, Vohr B. Importance of Parent Talk on the Development of Preterm Infant Vocalizations. PEDIATRICS. 2011 Nov 1;128(5):910–6.
23. Rand K, Lahav A. Impact of the NICU environment on language deprivation in preterm infants. Acta Paediatr Oslo Nor 1992. 2014 Mar;103(3):243–8.
24. Vohr B, McGowan E, McKinley L, Tucker R, Keszler L, Alksninis B. Differential Effects of the Single-Family Room Neonatal Intensive Care Unit on 18- to 24-Month Bayley Scores of Preterm Infants. J Pediatr. 2017 Jun;185:42-48.e1.
27. Franck LS, Axelin A, Van Veenendaal NR, Bacchini F. Improving Neonatal Intensive Care Unit Quality and Safety with Family-Centered Care. Clin Perinatol. 2023 Jun;50(2):449–72.
28. Lester BM, Salisbury AL, Hawes K, Dansereau LM, Bigsby R, Laptook A, et al. 18-Month Follow-Up of Infants Cared for in a Single-Family Room Neonatal Intensive Care Unit. J Pediatr. 2016 Oct;177:84–9.
29. Klemming S, Lilliesköld S, Westrup B. Mother‐Newborn Couplet Care from theory to practice to ensure zero separation for all newborns. Acta Paediatr. 2021 Jul;apa.15997.
30. Lyngstad LT, Le Marechal F, Ekeberg BL, Hochnowski K, Hval M, Tandberg BS. Ten Years of Neonatal Intensive Care Adaption to the Infants’ Needs: Implementation of a Family-Centered Care Model with Single-Family Rooms in Norway. Int J Environ Res Public Health. 2022 May 13;19(10):5917.
Second edition, December 2024. Previous edition reviewed by Dr Elodie Zana Taieb.
Lifecycle
5 years/next revision: 2029
Recommended citation
GFCNI, Moen A, Tandberg BS B et al., European Standards of Care for Newborn Health: Core principles of NICU design to promote family-centred care. 2024.
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