Family‐centred care change during COVID‐19

Abstract Background Family‐centred care (FCC) is an approach to promote family and health care provider partnership. This has been incorporated into neonatal intensive care units (NICUs) worldwide. However, FCC in low resource health settings, such as Thailand, is challenging and further impacted by coronavirus disease 2019 (COVID‐19). Aims To evaluate FCC innovations to improve respect, collaboration and support in a Thai NICU. Study design A quasi‐experimental study was conducted in an NICU in southern Thailand. Pre‐implementation was prior to COVID‐19, and parental and staff perceptions of FCC were measured via Perceptions of Family Centred Care‐Parent (PFCC‐P) and ‐Staff (PFCC‐S) survey. The FCC innovations were developed by stakeholders based on the COVID‐19 restrictions, pre‐survey results, parents' and clinicians' interviews and integrative review, then implemented via a flowchart. Post‐implementation evaluation was via repeated surveys. Comparisons were made pre‐and post‐implementation, with Mann–Whitney U‐test statistics for parents and Wilcoxon's Rank Sum for staff. Results A total of 185 (85 pre; 100 post) parents and 20 (pre and post; paired group) health care professionals participated. Because of COVID‐19, many planned interventions were unfeasible, however, other innovations achieved (e.g., structured telephone updates, information booklet revision). There was an increase in parents' perception of respect ([median] 2.50–3.50), collaboration (2.33–3.33) and support (2.60–3.60) domains and overall (2.50–3.43; p < .001; 95% CI: 2.93–3.11). Interdisciplinary professionals' perception of FCC did not significantly change pre‐and post‐implementation/COVID‐19 pandemic for respect (3.00–2.92), collaboration (3.22–3.33), support (3.20–3.20) and overall (3.15–3.20; 95% CI: 3.10–3.25). Conclusion Despite the challenges of COVID‐19 restricting NICU access, the provision of FCC was maintained and even improved. Relevance to clinical practice Further research is necessary to develop FCC practice innovations associated with communication, across diverse health care systems and resources.

established system, with nurses having reduced authority in designing the services or provision of flexible care delivery. 20 Additionally, due to staffing-level nurses prioritizing routine physical care provision, responsive services for family needs are unmet. 21 In Thailand, nurses' perceive FCC as a Western concept, with nurses' attitudes towards their roles, and a nursing shortage being obstacles to implementing FCC. 18 Moreover, family needs, individuality and the Thai health care system further impact successful implementation of FCC. 18,22 Neonatal nurses have questioned whether the implementation of FCC in the NICU can contribute to changes in practice and organizations. 23 COVID-19 has impacted family interactions across health care, which has had the biggest impact on neonatal and paediatric intensive care units. 24 Paediatric nurses in Italy identified that they provided a flexible service to maintain their FCC model; however, the impact this had on families and staff has not been explored. 24 The international context of FCC in NICUs during COVID-19 has not been explored, especially in low-resource countries such as Thailand. During coronavirus disease 2019 (COVID- 19), parents' and interdisciplinary professionals' perceptions about the key elements of FCC in a Thai NICU are even more important.

| Aims and objectives
This study aimed to evaluate whether practice innovations, implemented in a Thai NICU, facilitate FCC by improving parents ' and What is known about the topic • In NICUs around the world, FCC is incorporated into clinical practice and widely used.
• Implementation of FCC in low-resource health care settings is challenging due to complex and diverse political, social, cultural and economic characteristics.
• COVID-19 has impacted care delivery for neonates and their families in NICUs, including visitation policies, developmental care and communication practices.

What this paper adds
• Implementation of practice innovations in NICU has improved parents and health care providers perceptions of the FCC elements of respect, collaboration and support.
• Despite COVID-19, parents responded positively to the FCC innovations implemented into daily practice.
• Communication is necessary to work collaboratively with parents to promote partnerships in care during the social distancing and public safety of COVID-19.
interdisciplinary professionals' perceptions of respect, collaboration and support, including during COVID-19.

| Design
The study was conducted using a quasi-experimental design (pre, post) to evaluate the effects of FCC innovations developed based on current policies and practices in Thai NICU. The Ministry of Public Health of Thailand announced the first confirmed cases of COVID-19 on 6 February 2020; 25 however, changes to hospital policy regarding visitation were put into place from the 21 March 2020. The pre-implementation period was prior to the COVID-19 pandemic policy changes (February-20 March 2020), while the implementation (September-October 2020) and post-implementation (November 2020-January 2021) periods were during COVID-19.

| Setting
The study was conducted in a 20-bed, level IV NICU in a tertiary care hospital in southern Thailand with approximately 500 admissions per year from across southern Thailand (500 kilometres), approximately 32 nurses, two physicians (one professorial/senior specialist staff, one Resident) and one pharmacist.

| Participants and sample
A purposive sampling approach was used to recruit parents and interdisciplinary professionals via daily screening of admission records. After seeking permission to approach parents from their health care provider, the researcher recruited participants (parents) during visiting hours. The interdisciplinary professionals were recruited through ward-based advertising by internal mail using staff roster in-service times. A sample size of 100 parents and 20 interdisciplinary professionals pre-and postimplementation was feasible (i.e., availability of parents over three-month periods; 57% of total staff). 26 Parents and interdisciplinary professionals were required to satisfy the following inclusion criteria: • Parents of neonates with an expected NICU stay of at least 72 h, who visited the NICU at least once. This included all gestational ages, however, infants with a life-threatening or life-limiting diagnosis and requiring palliative care were excluded from the study, due to the potential influence on parents' experience.
• Interdisciplinary professionals (nurses, physicians, pharmacist), with a permanent position providing care activities for at least 1 year in the NICU.
• Thai speaking and reading participants.
Neonates of participating parents were also included for descriptive purposes.

| Ethical approvals
Ethical approvals were obtained from the hospital's and University Human Research Ethics committees (16th December 2019; 20th January 2020, respectively). Participants were provided with verbal and written information detailing the purpose of the study and right to withdraw consent. Confidentiality and anonymity of participants were maintained throughout the study by using unique participant numbers. 27 Written consent was obtained.

| FCC innovations
The FCC innovations were developed based on an integrative review, 28 surveying parents' and interdisciplinary professionals' perception of FCC and interviewing nine parents and eight health professionals. 29 Although a preliminary protocol for the intervention and The FCC innovations were considered within the current policies and practices of the NICU, including low-scoring items from the preintervention survey. In addition, the findings from the interviews (reported elsewhere) 20 identified that the interdisciplinary professionals accepted the necessity of FCC for daily practice, but parents' participation in neonatal care was perceived as an obstruction to providing care. 29  • *Telephone call (at least three times per week) to update newborn progress and treatment in NICU.
• *Interdisciplinary family meeting for complex care situations.
• Information booklet, e-booklet and paper-based (revised) with the details for the COVID-19 situation including NICU introduction: environment; staff; NICU policies; visiting management, important information and parental education during admission to NICU.
(*with structured communication checklist and documentation template) To assist with implementation of these revised practices, in August 2020, there were theoretical, case study and practical training activities held by the development working group for the health care professional team (80% of team attended). Likert scale (never, sometimes, usually, and always), with scores ranging from 1 to 4, respectively. 31 For each respondent, a median score was calculated for respect (average response for 9 items), support (average response for 6 items), collaboration (average response for 5 items) as well as overall. 31 The PFCC-P and PFCC-S were translated from English into Thai, utilizing the guidelines for translation and cultural adaptation from the International Society for Pharmacoeconomics and Outcomes

| Data collection, context and instruments
Research (ISPOR). 34 Permission from the authors to use and translate the questionnaires was obtained. Cronbach's alpha coefficient of the PFCC-P and PFCC-S was 0.907 and 0.663, respectively.
In addition, demographic details were collected, including neonates', parents' and interdisciplinary professionals' characteristics, including the neonates' hospital records.

| Data analysis
Demographic characteristics of parents, interdisciplinary professionals and neonates are reported using descriptive statistics, including frequencies (percent) and median (interquartile range [IQR]), relevant to data distribution and characteristics. Negatively worded items were reverse coded prior to calculation, as per previous uses of the FCC tool. 31 The data were not normally distributed, so medians were used for each of the three sub-scales. The statistical technique Mann-Whitney U-test was used to analyse parents' perception on the items of the PFCC-P in the pre-and post-implementation (unpaired groups).
Wilcoxon's Rank Sum was used to compare the perceptions of the interdisciplinary professionals pre-and post-implementation using the PFCC-S (paired groups). 35 The non-equivalent sample in the group of parents was justified by the turnover of patients in the NICU. For the NICU health care team, 20 participated.

| Parents
An equal number of males and females participated, as shown in Table 1. Most participants were aged between 21 and 30 years old (52%-60%), completed high school (39%-41%) and spent an average of 30 min-1 h travelling to the hospital.

| Neonates
There were notable demographic differences in neonates admitted to NICU between pre-and post implementation. The most common diagnosis was prematurity, 36% (n = 18) pre implementation and 40% (n = 21) post implementation. The median length of stay was eight (pre) and six (post) days. All neonates pre implementation were not readmitted, while 5.8% post implementation were readmitted after NICU discharge (Table 1).

| Interdisciplinary professionals
As a matched sample, the data are the same pre and post implementation. All participants were female and completed Bachelor's degree, mainly nurses (95%), aged between 31 and 40 years (40%), and had been working in NICU for 1-5 years (30%) ( Table 2).  Table 3 shows the scores of parents' and interdisciplinary profes-  (Table S1).
Regarding interdisciplinary professionals, there was an important difference (at least 10% of the rating scale) between pre and post implementation to demonstrate a more positive perception for item 2, "When parents come to the unit they feel welcome" and item 11 "Parents are taught what they need to know about their baby's care" (Table S1).

| DISCUSSION
The key finding to emerge from this study was that parents positively perceived FCC improved, despite the restrictions associated with COVID-19. Comparatively, the interdisciplinary professionals' total responses did not change, despite these same challenges.
The sample of this study is likely to be representative of their respective populations in Thai NICUs. For parents' demographic, education level and age, parenthood reflects Thailand's NICU parents' characteristics. 37 Interdisciplinary professionals' characteristics of this study reflect the gender of the occupational groups in NICU and experience in NICU. 18

| Implication for practice
Implementing innovations relating to the Thai health care context was essential to reinforce the effectiveness and sustainability of FCC, even prior to COVID-19. In this crisis of COVID-19, there is an opportunity to look at problems from the new perspective and create FCC innovations in NICUs that make it possible to maintain and even improve FCC implementation. These innovations can now be used to influence broader and more diverse strategies, including health care systems and resources. In addition, physical presence is not always possible, particularly in the social distancing context of COVID-19. Therefore, it is imperative to develop family nursing interventions and provide sufficient resources to help health care providers work collaboratively with families to maintain a vital presence in daily communication in the NICU.