Nurturing staff to nurture families:
Strategies to provide education, systems building
and reflection
Inga Warren, MSc
University College London Hospital
Pani Pantelides
“… hospitals should consider the need to nurse the
nurse to bolster well-being of the staff and ultimately
facilitate the nurturing of families” Roberta CriccoLizza 2014
What is expected of us: the underrecognised demands of emotional labor
(Cricco-Lizza 2014, Wigert 2014, Cleveland 2008)).
 A warm welcome at all times
 Permanent “happy face”
 Controlled emotions
 Cultural sensitivity
 Clear and personal communication
 Attentive listeners
 A human being
 Partnership with parents
 Support parenting roles
 Promote parent-baby
interaction
 Constancy
 Cope with challenging
behaviour
Nurses expend labor to control emotions and to present to
babies and parents a work persona of competence and
composed professionalism (Cricco-Lizza 2014)
What happens to us?
Stress, burnout and compassion fatigue.
(Profit 2014, Boyle 2011)
 Tired
 Sad, depressed
 Angry
 Apathetic
 Sleep disturbance
 Moral distress
 Health problems
 Absenteeism
 Unable to keep up and
change
 Poor work life balance;
impact on families
 High staff turnover
 Low job satisfaction
Burnout related to conflict within work setting
Compassion fatigue related to interpersonal
intensity
Impact of burnout / compassion fatigue on
patient care
 Poor safety culture
 Higher rates of error
 Suboptimal care e.g. increased risk of infection
 Parent dissatisfaction
 Complaints and law suits
 Difficulty achieving quality improvements
Profit 2014, Prins et al 2009, Rochefort and Clarke 2010
Parent support is an important component of
interventions for pre-term infants
 11/18 studies had outcomes for parents (2/18 fathers)
 Positive effects on anxiety, depressive symptoms and
self efficacy
 Interventions with psychosocial support had better
outcomes.
 Parenting education - positive effect on anxiety.
 Parenting education alone did not reduce stress.
Parent support component did have an effect.
Benzies, K M., et al. "Key components of early intervention programs for
preterm infants and their parents: a systematic review and metaanalysis." BMC pregnancy and childbirth 13.Suppl 1 (2013): S10.
Four influencing factors in a NICU parent's progression:
1. contact with and proximity to their infant,
2. relationship with the nurse,
3. having information,
4. social support.
VazQuez V, Cong X (2014), Parenting the NICU infant: A meta-ethnographic
synthesis International Journal of Nursing Sciences 1(3):, 281–290
“Nurses must engage
with NICU parents in such a way as
to maximize the likelihood that these parents will reach at
minimum the proficient and at maximum the expert
parenting stage by discharge”.
CLOSENESS AND CONNECTION
Closeness
Flacking R et al for the SCENE group 2012, Closeness and
separation in neonatal intensive care, Acta Paed
Emotional connection
Hane A et al Family Nurture Intervention improves the quality of
maternal caregiving in the neonatal intensive care unit : Evidence
from a RCT. J. Dev. Behav. Pediatr. 2015
STRATEGIES
for nurturing staff and building resilience.
Self
maintenance
Systems
organisation
Reflection
Education
(? and
mindfulness)
1. SELF MAINTENANCE: : “responsible selfishness”
(Jones 2005)
 Work-life balance
 Exercise
 Diet
 Distractions
 Diary/journal
 Meditation
 Massage
Connect
Learn
(Be) Active
Notice
Give back
Eat well
Relax
Sleep
(Phillip Hammond)
Does your institution support self
maintenance: good food, health
services, fitness support, child care?
Accelerated Recovery Program (ARP)
(Gentry et al 2000)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Understand triggers
Review methods for coping
Caregiver plans for self treatment
Resources for addressing compassion fatigue
Teach effective self-soothing
Teach grounding and containment skills
Enhance proficiency in self care and boundary setting
Video- dialogue techniques for self supervision
Self administered, self care planning
2. SYSTEMS ORGANISATION.
 Policies – compatibility with family centred philosophy.
 Attitudes to FCDC. Being allowed to deliver good quality care
 Ratio of senior staff (Turner 2014)
 Rostering
 Group size - magic number: 150 (Dunbar 1992)
 Equal opportunities (Williamson 1992)
Constant organisational change (influenced by competition,
technology, legal/regulatory constraints) is EXHAUSTING
(Cricco-Lizza 2014)
EQUAL OPPORTUNITIES
Policies don’t implement themselves.
Wallin et al 2004, Staff experiences in implementing guidelines for
kangaroo mother care. Int J Nurse Studies.
Evidence based
guidelines
4 units: Change team
2 units: FACILITATOR
Change activities
Focus groups.
ARRC project, Sheffield (Skene)
Action Research on Relationship Centred Care
Exploration
• Parent and staff surveys
• Parent and staff focus groups
• Baseline data
Intervention
cycles x 3
•
•
•
•
Evaluation
• Parent and staff focus groups
• Parent and staff interviews
• Compare with baseline data
Planning
Acting
Observation
Re-planning
3. ENVIRONMENT:
.
Space to help parents interact
with their baby
Space to talk to parents
privately
(Wigert 2014, Turner et al2014)
Feilden Clegg 2011
Impact of single room design on staff:
• Increased workload and isolation
• Increased satisfaction from benefits to infants and families.
(Hagen et al 2015)
AESTHETICS – impact on well-being and
confidence in the institution.
Lankston et al 2010. Ulrich and Gilpin, 2003. Behrman 1997
Colour
Art work
Lighting
Daylight
Views of nature
References to nature
Fluorescent Gallery
ENVIRONMENTAL STRESSORS
(White et al 2013, Ulrich 2004),
• Light: bright areas for breaks and work surfaces; light
showers for night staff; morning light.
• Sound levels and characteristics - fatigue, errors,
communication
• Temperature (Williamson 1993) and ventilation
An environment that is appropriate, safe and
healthy for infants, parents, and STAFF
SOCIAL ENVIRONMENT
 Community – “the village effect”
(Pinker 2014); shared
food, book swop,
birthdays, events.
 Space to take breaks, to meet, eat,
talk, chat, and laugh together
• Culture of mutual assistance and respect (Williamson 1992)
• Psychological support; relationships; moral dilemmas
• Protection e.g. from aggressive behaviour, bullying
RELATIONSHIPS WITHIN THE SYSTEM
 Parents are sensitive to power
struggles, difficult relationships and
inconsistencies in the system
 Adopt deferential behaviour with staff
and anxious surveillance to protect
baby.
Finlayson K, Dixon A, et al (2014), Mothers perceptions of
family centred care in neonatal intensive care units, Sexual
and Reproductive Healthcare
LEADERSHIP
Transformational leadership (Nielsen et al 2009); Leaders and their
followers raise one another to higher levels of morality and
motivation: vision, identity, role modelling, strengths and
weaknesses.
Management style – visibility, fairness, walk rounds,
feedback (Sexton et al 2014).
Good manners – rudeness undermines performance (Riskin et
al 2016)
Developmental care team, (Hendricks-Munoz et al 2007).
3. EDUCATION – Recommendations for enhancing
psychosocial support of NICU parents through staff education
and support. Hall et al 2015, J Perinatol)
 “Normal” responses to infant hospitalisation
 Mood and anxiety disorders
 Family Centred Developmental Care
 Cultural sensitivity with self awareness and flexibility
 Self care
 Competent communications
Focusing on staff training alone is insufficient as it neglects
employment practices and issues of management style that
contribute to burnout. Hall et al 2015
COMPETENCIES:
Relationship based (Warren and Brown 2014)
 Relationship with the Infant
 Relationship with the Family
 Relationships within the system
The most effective way to learn
Rate of transfer into classroom practice following peer
coaching
100%
90%
80%
70%
95%
Workshop
Workshop and modeling
Workshop, modeling and practice
60%
50%
Workshop, modeling, practice and feedback
40%
Workshop, modeling, practice, feedback and peer
coaching
30%
20%
10%
10%
13%
14%
19%
0%
1
Bush RN, 1984, Effective staff development.
COACHING: what makes it work?
 Job embedded: directly applicable to practice
 Focused on a few highly important strategies
 Intensive (one-to-one)and on-going
 Partnership: equal partner / collaborator with coach
 Dialogue: reflective conversations
 Non-judgemental and confidential
 Respectful, open and honest communication
 Management interest and support
 Voluntary
 Coach needs deep understanding of area of work
Adapted from Knight J, 2009,
Training with COACHING component and improved
parent outcomes
• NIDCAP (Als 1985, 2003)
• Mother Infant Transaction Programme (Rauh
1990. Kaareson 2006, Newnham 2009)
• Family Nurture Intervention (Welch 2012, Hane
2015))
Author
Year
Country
Impact on parents
Als et al.
2003
USA
Wielnga
et al
2006
Nether- • Parents more satisfied with care given
lands
according to NIDCAP than with traditional
care.
Kleberg
et al
2007
Sweden •
• Lower family stress and enhanced
appreciation of the infant.
•
Van der
Pal et al
2007
Perceived more closeness to their infants
than control mothers (p=0.022)
Rated staff’s ability to support them in their
role as a mother higher
Nether- • No significant differences were found in
lands
confidence, perceived nursing support or
parental stress.
Newborn Individualised Developmental
Care and Assessment Programme.
Author
Year
Country
Rauh et al
1998 USA
Impact on parents
Greater satisfaction and confidence with
mothering. More favourable perceptions of
infant temperament
Kaaresen et 2006 Norway
al
Mothers and fathers in the intervention
group reported significant lower scores in
child domain, parent domain, and total
stress
Newnham
Mothers less stressed by their infant at 3
months.
2009 Australia
Mother Infant Transaction Programme: staff trained with
Brazelton Neonatal Behavioural Assessment Scale.
Close Collaboration with Parents Training
Programme, Ahlqvist-Bjorkroth S et al (2013)
• Increased parental
involvement in infant care.
• Increased interaction with
parents.
• The role of the nurse changed
from an active caretaker to a
facilitator
Axelin et al 2014, Nurses' perspectives on
the close collaboration with parents
training program in the NICU.
Communication skills
 “Limited conversation” (McCarthy et al 2013)
 Education in use of translators
 Using simple, non-technical, language
 Availability of printed materials – words and pictures
Programme to Enhance Relational and
Communication Skills (PERCS-NICU) (Meyer et al
2011 Boston)
 Interdisciplinary workshops (6h): 10-15 participants and 3
facilitators
 Collaborative exercise, educational film, didactic
presentation
 Case scenario with actors
 Conversation, feedback, reflection, action plans
RESULTS: questionnaire at 12 m
100% : improved preparation, communication skills and
confidence
83%: reduced anxiety
Neonatal Critical Care Communication (NC3)
(Boss et al 2013)
 13 Medical and NNPs
 3 day retreat
 Didactic overviews (10 key communication skills)
 Facilitated groups with role play (actors)
 Written curriculum (referenced) with 6 modules, which
included specific skills such as ask-tell-ask; jargon free
language; open ended questions
RESULTS ( Surveys before, during and 1 month after)
• Improvement in perceived competence in 10 key skills
• More confident to talk to families
4. REFLECTION
Thinking about who we are, what we do, and who
we want to be. Learning from experience.
Rosalie
Fiennes
2014
REFLECTION
Menu of work setting options (Boyle 2011)
 On-site counselling
 Staff support groups
 De-briefing sessions
 Art therapy
 Massage
 Encourage integration of self care plans into performance
appraisals
 Talking with the sisterhood” (Cricco-Lizza 2014)
 VERP: Video Enhanced Reflective Practice: video clips of self
at work to discuss in supervision
SHARING STORIES
An example from palliative care. (Campion Smith 2011)
 Six 2 hour sessions
 Topics / weekly themes







Symptom control
Communication
Benefits
Family issues
Ethics
Emergencies
Organisation of care
 Multidisciplinary groups to share stories on the theme of the
day - feedback ideas.
 Fast feedback forms, one-to-one telephone interviews 5
months later.
Modified KIRKPATRICK’S LEVELS OF EVALUATION
(Barr et al 2000)
1. Learners’ reactions
2a. Modification of attitudes and perceptions
2b. Acquisition of knowledge and skills
3. Change in behaviour
4a. Change in organisational practice
4b. Benefits to patients and relatives/carers.
• Technique of listening to others’ experiences and
sharing stories was an effective way to cross interprofessional boundaries.
• Evaluation was positive for all domains.
Holding staff who hold parents in the NICU
Psychoanalytic perspectives (Kraemer
2006, Cohen 2003)
 Ambivalence about psychological support (Profit 2014)
 “Clinging to fragmentation of care” - detachment, denial and
depersonalisation as coping strategies.
 Seek relief from the draining Intensive contact with families
 Resistant to putting themselves in the parents’ shoes.
Psychotherapists have a powerful role as translators and
meaning makers. They can help to structure free-floating
chaos and to provide shape and context to wordless
anxieties. Kraemer 2006.
SUPPORTING PARENTS TO REFLECT (Underdown 2013)
 Capacity to “mentalise” – interpret behaviour in
terms of underlying feelings – important for
developing sensitive interactions.
 Parents with low reflective function more likely to
misinterpret baby’s behaviour.
 Opportunities for parents to develop perceptions of
their baby as a person – likes, dislikes, strengths and
sensitivities.
Other opportunities and ways
to enhance job satisfaction .
 Seeing the benefits of
quality care – audit and
feedback
 Visits from children

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