children

Review
Nursing Perspective of the Humanized Care of the Neonate and
Family: A Systematic Review
Sagrario Gómez-Cantarino 1 , Inmaculada García-Valdivieso 2, * , Mercedes Dios-Aguado 3 ,
Benito Yáñez-Araque 4 , Brigida Molina Gallego 1 and Eva Moncunill-Martínez 5

1 Department of Nursing, Campus Toledo, Physical and Occupational Therapy University of Castilla-La
Mancha, 45071 Toledo, Spain; [email protected] (S.G.-C.); [email protected] (B.M.G.)
2 Mostoles University Hospital (HMOS), Madrid Health Service (SERMAS), 28935 Mostoles, Spain
3 Yepes Health Center, Castilla-La Mancha Health Service (SESCAM), 45313 Toledo, Spain;
[email protected]
4 Department of Physical Activity and Sports Sciences, University of Castilla-La Mancha, Campus Toledo,
45071 Toledo, Spain; [email protected]
5 Toledo Hospital Complex (CHT), Neonatal and Pediatric Oncology Unit, Castilla-La Mancha Health
Service (SESCAM), Theoretical Collaborator University of Castilla-La Mancha, Campus Toledo,
45071 Toledo, Spain; [email protected]
* Correspondence: [email protected]; Tel.: +34-916-64-86-00 (ext. 8728)

Abstract: This systematic review aims to determine the extent to which published research articles
show the perspective of health professionals in neonatal intensive care units (NICU), as facilitators of
family empowerment. Studies conducted between 2013 and 2020 were retrieved from five databases
(PubMed, Cochrane, CINHAL, Scopus, and Google Scholar). The search was carried out from
January to October 2020. A total of 40 articles were used, of which 13 studies (quantitative and



qualitative) were included in this systematic review. Its methodological quality was assessed using

 the mixed methods assessment tool (MMAT). In these, the opinions and perspectives of professionals
Citation: Gómez-Cantarino, S.; on the permanence and participation of parents were valued. In addition, the training, experiences,
García-Valdivieso, I.; and educational needs of nursing within the NICU were determined. The crucial role of health
Dios-Aguado, M.; Yáñez-Araque, B.; professionals in the humanization of care and its effect on the neonate-family binomial was estimated.
Gallego, B.M.; Moncunill-Martínez, E. However, conceptual changes are needed within the neonatal intensive care units. To implement
Nursing Perspective of the humanization in daily care, family participation should be encouraged in them. For this, it is
Humanized Care of the Neonate and
necessary to modify hospital health policies to allow changes in the infrastructure that facilitate open
Family: A Systematic Review.
doors 24 h a day in special services.
Children 2021, 8, 35. https://doi.org/
10.3390/children8010035
Keywords: infant newborn; pediatrics; neonatal nurses; psychosocial; critical illness; family; empow-
erment; nursing education; nurse training
Received: 14 December 2020
Accepted: 7 January 2021
Published: 9 January 2021

Publisher’s Note: MDPI stays neu- 1. Introduction

tral with regard to jurisdictional clai- The role of nursing in the care of newborns (NB) in neonatal intensive care units
ms in published maps and institutio- (NICUs) has evolved over time. This environment has a negative impact on the growth
nal affiliations. of newborns. Therefore, it is of vital importance to attenuate the stimuli, in order to
favour adequate neurological development in the newborn. The newborn individualized
developmental care and assessment program (NIDCAP method) aims to individualize
Copyright: © 2021 by the authors. Li-
care, observing and assessing in a comprehensive way the developmental state, and the
censee MDPI, Basel, Switzerland.
ability to cope with the stress of the NB before, during, and after each procedure.
This article is an open access article
Currently, we are reaching a more humanized assistance and integrating the family
distributed under the terms and con- as a fundamental part in the care of the newborn and, in turn, including them as main
ditions of the Creative Commons At- caregivers from birth [1–3]. Previously, the administration of inpatient care involved the
tribution (CC BY) license (https:// separation of the newborn and the family.
creativecommons.org/licenses/by/ Even the scarce presence of parents during the estimated time of visits was perceived
4.0/). by health professionals as a possible risk factor for the health of the sick newborn. A matter

Children 2021, 8, 35. https://doi.org/10.3390/children8010035 https://www.mdpi.com/journal/children

Children 2021, 8, 35 2 of 19

that left parents outside the basic and technical care provided in the NICUs to their
children [4,5] was that the family was considered as a stressor and not as a receiving
and giving part of care [6]. Currently, the child and his/her family are perceived as an
indivisible unit, recipient of care since the sick child belongs to a family with its own rules
and norms [7].
For the multidisciplinary team, and in particular, for the nursing professionals, inte-
grating the family as a fundamental part of care within the NICUs supposes a change of
perspective to involve the family as the main carers. Therefore, the role of nursing has gone
from being one of the main caregivers of the newborn within the NICUs to being, at present,
a collaborative staff and facilitator of the empowerment of parents [2,8]. This involves the
development of new knowledge, skills, and abilities for healthcare professionals, which in
the past were of little importance.
The family-centered care (FCC) model carried out in various NICUs returns the impor-
tance of the neonate-family binomial as an indivisible unit to be cared for [6,9,10]. To carry out
this new model of care, it is necessary to provide the multidisciplinary team that attends these
units with updated knowledge, tools, and training resources to guarantee quality care based
on safety and establish a relationship of trust between healthcare personnel and the family.
Among these new skills are techniques to establish efficient communication, which
enables adequate health education. This provides parents with the necessary resources to
carry out their role as primary caregivers [1,4,7,8]. This situation requires specialist pediatric
care nursing, to ensure quality care in healthcare. In turn, it is necessary to offer strategies
for coping with the stress that working in a NICU unit may entail. Multidisciplinary
workspaces are also necessary, where health personnel and families contribute their vision
and feel respected within it. NICU nurses positively value training in the FCC model since
it is a tool that guides them in the behavioral elements to observe and, in this way, assess
and plan care related to the observed behavior [3,11].
The transition to FCC in a stressful environment such as NICUs favors and improves
the involvement of parents in the care of their child. It improves communication between
the family and health personnel, contributes to the reduction of stress and conflicts, and
favors the empowerment of the family as a care provider. This question enables technique
and humanization to be harmoniously balanced [5–7].
The aim of this systematic review is to make the nursing perspective visible within
the NICUs, in relation to the healthcare provided to the neonate–family binomial, which is
a challenge within these special units, both professionally and in terms of infrastructure.
It even investigates the basic and specialized training level that nurses, both new and vet-
eran, have for the development of their skills. The nursing aptitude to function adequately
is also perceived, in a highly instrumentalized environment, but where humanized care is
highly valued, becoming indispensable.

2. Materials and Methods

A systematic review has been carried out following the Prisma guide [12], carrying
out an exhaustive search in five databases (PubMed, Cochrane, CINHAL, Scopus, and
Google Scholar) for articles published from 2013 to 2020. The results of the research
were synthesised using strategies that avoid bias and random error. These strategies
included systematic sorting of all potentially relevant articles and the description of the
methodological design. They also included the analysis and the extraction of information
from the articles, as well as the presentation and interpretation of the results.
The search was conducted from January to October 2020. This was due to the difficulty
of including studies that reflected the experience and training of nurses within NICUs.
It was also due to the need to incorporate studies that encompassed the perspective of
humanization of care in terms of both nursing and family.
Research, which includes qualitative and quantitative designs, has been used in this
type of study. The search terms and threads that were used are reflected below (Table 1).
Children 2021, 8, 35 3 of 19

Table 1. Search strategy in databases.

Database Search Strategy Limits Filters

PubMed Infant newborn OR Pediatrics 190 items filtered
AND Neonatal nurses OR
Cochrane Title 85 items filtered
Caregivers AND Critical care OR
CINHAL Critical illness AND Family Article 124 items filtered
AND Empowerment AND English/Spanish
Scopus 107 items filtered
Psychosocial AND Nursing
Google Scholar Education AND Nurse Training 236 items filtered

2.1. Selection Criteria

Papers retrieved during the searches were checked against the following inclusion
criteria: (1) full-text original report published in a peer-reviewed journal; (2) articles that
include the nursing perspective on family involvement in NICUs (Level I, II, and III);
(3) studies indicating NIDCAP experiences and training needs of nursing; (4) research that
includes the FCC model; and (5) articles written in English or Spanish.

2.2. Data Extraction

The search was conducted by four reviewers (S.G.-C., I.G.-V., M.D.-A., and B.Y.-A.).
They read the titles and abstracts of all articles retrieved. When there were doubts about the
inclusion of an article in the research, it was resolved by the consensus of the entire research
team (S.G.-C., I.G.-V., E.M.-M., B.Y.-A., B.M.G., and M.D.-A.). Information about the
author, year, country, study design, study purpose, sample characteristics, main variables,
methodological quality level, results, and limitations was extracted from all studies. The
results of studies that met the selection criteria were screened for retrieval.

2.3. Assessment of Quality and Level of Evidence

The quality of the selected studies was scored using a critical appraisal tool designed
for systematic reviews that include qualitative, quantitative, and mixed studies and called
the mixed-method appraisal tool (MMAT) [13]. The MMAT was developed in 2006, re-
vised in 2011, and its latest version was published in 2018, which has been used in this
article [13]. The list contained five items related to sample size, study measurement, design,
presentation of results, and quality of research.
The total quality scores of the studies were calculated by adding up the scores of the
five elements individually (range: 0–10). They were also used to categorize the level of
evidence provided: studies were defined as high quality (HQ) if they had a total score of
eight or more; a total score of five to seven was defined as medium quality (MQ); a score
below five was defined as low quality (LQ).
Four reviewers (S.G.-C., I.G.-V., M.D.-A., and E.M.-M.) assessed study quality sepa-
rately. In addition, a meeting was held to resolve possible disagreements between all the
reviewers (Table 2).

Table 2. List of included studies with quality scores.

Author(s) A B C D E Total Score Quality Level

Coyne et al. [14] 2 1 1 1 1 6 MQ
Mosqueda et al. [15] 2 2 2 2 1 9 HQ
Mosqueda et al. [16] 2 2 1 1 1 7 MQ
Mosqueda et al. [17] 2 2 2 2 1 9 HQ
Kjellsdotter et al. [18] 2 2 1 1 1 7 MQ
Kucuk et al. [19] 1 1 1 1 0 4 LQ
Baghlani et al. [20] 2 2 2 1 1 8 HQ
Axelin et al. [21] 1 1 2 2 1 7 MQ
Coasts et al. [22] 1 1 1 2 0 5 LQ
Toivonen et al. [23] 1 2 2 1 0 6 MQ
Children 2021, 8, 35 4 of 19

Table 2. Cont.

Author(s) A B C D E Total Score Quality Level

Gilstrap et al. [24] 1 2 2 2 1 8 HQ
Heidari et al. [25] 1 2 2 2 1 8 HQ
Mirlashari et al. [26] 1 2 2 2 1 8 HQ
HQ: high quality; MQ: medium quality; LQ: low quality. A: sample size (2: more than 100 participants; 1: 10 to
99; 0: fewer than 10 participants); B: study measurement (2: suitable; 1: not very suitable; 0: nothing suitable).
C: design (2: suitable; 1: not very suitable; 0: nothing suitable). D: presentation of results (2: relevant; 1: not very
relevant; 0: not relevant). E: quality of research (2: very good; 1: good; 0: low).

3. Results
3.1. General Findings
Once the selected articles were evaluated, it was found that of the 13 included studies,
six (46.14%) obtained a score of between 8–10 points, which indicates their high qual-
ity [15,17,20,24–26]. Three of them (23.07%) belonged to qualitative studies, and another
three (23.07%) belonged to quantitative studies. On the other hand, five (38.46%) articles
were classified as medium quality studies [14,16,18,21,23]. Two (15.38%) of these articles be-
longed to qualitative research, while three (23.08%) belonged to quantitative studies. Only
two (15.38%) studies obtained a score indicating low quality after being analyzed [19,22].
One (7.69%) was a descriptive qualitative study and one (7.69%) a quantitative study.
The flow of search results through the systematic review process is displayed in
PRISMA. The initial search retrieved 742 articles, which were reduced to 487 by eliminating
duplicates. The titles and abstracts of these 487 studies were screened, resulting in the
exclusion of 329 additional studies. Of the 158 remaining, 145 were excluded because they
were not original studies, did not focus on the nursing perspective and were developed in
the pediatric intensive care units (PICU), and were related to hospital management. Thus,
13 studies were included in the systematic review (Figure 1).
Four studies [15,16,21,24] were conducted in hospitals with high technology (n = 6),
five studies [14,19,22,25,26] were conducted in general hospitals (n = 14), and four stud-
ies [17,18,20,23] in medium-sized hospitals (n = 82).
Regarding the types of studies selected, we found that seven (53.84%) are quantitative
studies, of which two (15.38%) were descriptive, two (15.38%) were multicenter, one
(7.69%) was cross-sectional, one (7.69%) was non-experimental, and one (7.69%) was
logistic regression. A total sample of quantitative studies of n = 2042 (92.94%) was obtained.
Regarding qualitative research, six (46.16%) studies were selected, since they met the
inclusion criteria, with a total number of participants of n = 155 (7.06%). The sample size of
the studies ranged from 10 [22] to 372 nurses [18]. The samples were collected from seven
different countries: one study in Ireland, three in Spain, one in Sweden, one in Turkey,
three in Iran, two in Finland, and two in the USA. Table 3 shows the main characteristics of
the selected studies with the participating health professionals.

3.2. Health Professionals’ Perspective on Parental Involvement

Once the gender variable was analyzed, the selected articles provided significant data,
yielding a total sample of n = 2362 professionals. Of these, n = 2197 (93.01%) were women,
while n = 165 (6.99%) were men. The latter professionals were related to the NICU, both
because they were specialists in neonatology and because they were hospital directors [18].
Therefore, it can be affirmed that the presence within the nursing profession is mostly
female because it is traditionally and culturally linked to care. Even within these units, it is
valued that the female presence is significantly higher compared to the male presence [18].
On the other hand, the age variable provides relevant information since in some of the
studies carried out in countries such as Ireland [14], Spain [15–17], Sweden, [18], Iran [20],
Finland [21], and the USA [22], it was observed that the mean age of health professionals is
approximately 30–40 years. This situation plays a prominent role in encouraging parents to
be close to their newborn. From the selected studies, it is highlighted that Spain, Finland,
 Children 2021, 8, 35 5 of 19

and Ireland [14–17,21] have a younger nursing population, aged 30 years (n = 259). On the
other hand, it is seen that Iran and the USA [20,22] have a mean age of 40 years (n = 43),
while Sweden [18] has the oldest nursing group with 40–50 years (n = 372) of a total of
n = 674 nurses. Research shows that the youngest professionals [16], although focusing
on the family as a unit of care and even showing respect for their preferences, are more
focused on technology, with their attention to the family being in the background. On
the other hand, middle-aged staff [20] promote interpersonal relationships, an issue that
increases family capacities in the care process. It is clear that the most organisational
level dedicated to management is developed in studies where the sample is larger [18],
as services are coordinated and favourable environments are provided within the unit
itself. Even decision-making is coordinated among the multidisciplinary team including
ren 2020, 7, x FOR PEER REVIEW the family. 5 of

FigureFigure
1. The1. flow of articles
The flow of articlesthrough thesearch
through the search process.
process.

Four studies [15,16,21,24] were conducted in hospitals with high technology (n = 6

five studies [14,19,22,25,26] were conducted in general hospitals (n = 14), and four studie
[17,18,20,23] in medium-sized hospitals (n = 82).
Regarding the types of studies selected, we found that seven (53.84%) are quantit
tive studies, of which two (15.38%) were descriptive, two (15.38%) were multicenter, on
Children 2021, 8, 35 6 of 19

Table 3. Characteristics of the studies showing: perspective, training, and humanization of nursing.

Quantitative Studies
Author(s), Year, and Country Study Design Study Purpose Sample Characteristics Main Variables Results Limitations

- Age:
• 20–30 years (88)
• 31–40 (114)
• 41–50 (38)
• >50 (10)
- Gender Small sample size.
Work experience is related to
FCCQ-R
• Female (236) more positive support for
questionnaire still
Investigate • Male (14) family involvement.
under development.
perceptions and - Work experience Updating knowledge helps
Coyne et al. Quantitative Low response rate
practices of nurses n = 250 NICU nurses nurses to apply the FCCs,
(2013) Non-Experimental • 0–5 (68) (33%).
about FCC and n = 7 hospitals but they are not able to
Ireland Survey • 5–15 (106) Only nurses’
examine the apply all the elements due to
• 15–20 (36) experience was taken
influencing factors. lack of resources,
• >20 (40) into account, not
organizational barriers,
families or other
FCCQ-R Questionnaire: hospital design.
professionals.
- Family-professional
collaboration
- Family recognition
- Emotional support
- Shared information.
Children 2021, 8, 35 7 of 19

Table 3. Cont.

Quantitative Studies
Author(s), Year, and Country Study Design Study Purpose Sample Characteristics Main Variables Results Limitations

- Sociodemographic:
• Profession:
Neonatologists
(40) Nurses (169)
Assistants (94)
No response (2).
• Age:
• 20–35 years (139)
n = 305 professionals • 36–50 (119) Carrying out the study
Identify: n = 164 professionals • >50 years (46) Knowing the opinions of in the middle of the
Quantitative
requirements, NICU N-III Madrid • No response (1). professionals makes it implementation period
Mosqueda et al. (2013) Multivariate Logistic
professional (H. 12 Octubre) • Gender: possible to improve can influence the
Spain Regression Analysis
perceived barriers n = 141 professionals • Male (23) conditions and perception of
(NIDCAP) NICU N-III Barcelona • Female (280) facilitate work. requirements and
(H. Vall d’Hebron) • No response (2). barriers.
• Time worked
• <5 years (135)
• 6–10 (68)
• >10 years (58)
No response (44).
- Information sources.
- Necessary resources.
- Perceived barriers.
Children 2021, 8, 35 8 of 19

Table 3. Cont.

Quantitative Studies
Author(s), Year, and Country Study Design Study Purpose Sample Characteristics Main Variables Results Limitations

- Sociodemographic:
• Profession:
Neonatologists No differences in
(40) Nurses (169) perception regarding the
Assistants (94) gender variable.
• No response (2). Younger professionals
• Age: more positive
n = 305 professionals • 20–35 years (139) For nursing, it means a
assessment of NIDCAP.
n = 164 professionals • 36–50 (119) greater workload.
Professionals H. Vall
Mosqueda et al. Explore professional NICU N-III Madrid • >50 years (46) Carrying out the study
Quantitative d’Hebron highest scores.
(2013) perception of (H. 12 Octubre) • No response (1). in the middle of the
Descriptive Neonatologists perceive
Spain NIDCAP application. n = 141 professionals • Gender: implantation process
NIDCAP more
NICU N-III Barcelona • Male (23) can influence the
positively, nurses feel it
(H. Vall d’Hebron) • Female (280) results obtained.
requires more time to
• No response (2). implement.
• Time worked NIDCAP improves
• <5 years (135) parent-professional
• 6–10 (68) relationship.
• >10 years (58)
• No response (44).
Children 2021, 8, 35 9 of 19

Table 3. Cont.

Quantitative Studies
Author(s), Year, and Country Study Design Study Purpose Sample Characteristics Main Variables Results Limitations
The participants knew
they were being
watched and evaluated.
Since the
Determine: questionnaires were
theoretical-practical - Level of knowledge anonymous, they did
before and after the The course improved the
course on not allow evaluating
Quantitative course, with a level of knowledge. The
Mosqueda et al. (2016) individualized care n = 566 professionals the pre and post levels
Observational questionnaire of 30 participants expressed a
Spain (NIDCAP) effect: n = 20 NICUs (N-III) of each participant or
Multicenter questions. higher level of
degree of knowledge professional group.
- Course satisfaction. satisfaction.
and professional Inability to evaluate
satisfaction aspects such as
acquired skills,
attitude change and
impact on patients.

Non-representative
Examine age, gender - Age sample of NICU
and profession n = 443 professionals - Gender Nursing believes that the professionals.
Quantitative - Profession
Kjellsdotter et al. (2017) association regarding (n = 372 nurses, involvement of parents The validation of the
Transversal - NICU experience
Sweden importance of NICU n = 71 physicians) is important. questionnaire used is
parental care n = 29 NICUs. - Hours worked week questioned.
participation. - Parents involvement Personal factors affect
how you respond.
Children 2021, 8, 35 10 of 19

Table 3. Cont.

Quantitative Studies
Author(s), Year, and Country Study Design Study Purpose Sample Characteristics Main Variables Results Limitations
It is necessary to increase
the number of nurses
who participate in the
- Age elaboration of protocols,
Know perception - Education level to increase the
Kucuk et al. - Marital status
Quantitative nurses working in n = 53 nurses implementation of the
(2017) - Nº. children It has no limitations.
Descriptive NICU on n = 4 NICUs. FCC.
Turkey - Work experience
family-centered care. Educational level,
- FCC knowledge marital status and
having children
positively influenced
nursing perception.

- Sociodemographic:
• Marriage The self-report method
Excellent knowledge and
Baghlani et al. Evaluate knowledge, • Nº of children of conducting
Quantitative perception of nursing.
(2019) perception nursing n = 120 NICU nurses. • Level of studies questionnaires may not
multicenter Greater satisfaction and
Iran (NIDCAP method) • Work field express reality.
more positive attitude
• Work shift Limited sample size

Qualitative Studies
Author (s), Year and Country Study Design Study Purpose Sample Characteristics Main Variables Results Limitations
Family-centered care
Describe nursing - Parents frequency in
Axelin et al. program: nursing Results not
experiences: training n = 22 nurses (NICU the unit.
(2014) Qualitative attitude change. generalizable.
parents influence in N-III) - Participation.
Finland Increase parents Subjective experiences.
the NICU.
participation.
Children 2021, 8, 35 11 of 19

Table 3. Cont.

Qualitative Studies
Author (s), Year and Country Study Design Study Purpose Sample Characteristics Main Variables Results Limitations

- NICU environment.
- Provision of critical
care. Nurses find
Describe nursing
- Nurse and family family-centered care
perceptions about
stressors. beneficial. But the
Coasts et al. benefits and
- Communication changes created in the They have no
(2018) Qualitative challenges of n = 10 NICU nurses.
challenges and NICU posed a challenge limitations.
USA providing
strategies. in the provision of care.
family-centered care
- Family participation in Policy changes must be
in the NICU.
care and decision made including nurses.
making.

- NICU Features:
• N◦ beds
• N◦ Patients/year
Nurses commitment and Unable to include
Explore professional • Gestation weeks
motivation to change NICU physicians.
perception regarding • N◦ nurses
their role, key in Subjective experiences
Toivonen et al. (2019) the implementation n = 19 NICU managers. • N◦
Qualitative program of nurses and
Finland of the parent training n = 32 nurses. neonatologists
implementation, parents managers.
program in neonatal - Professional Features: as partners in the care of No examination of
care.
• Gender the Newborn (NB). parental experiences.
• Work experience
• Middle Ages
Children 2021, 8, 35 12 of 19

Table 3. Cont.

Qualitative Studies
Author (s), Year and Country Study Design Study Purpose Sample Characteristics Main Variables Results Limitations
Educating parents:
Nurses rely on
informing to improve the Only female nurses
communication to build
health and well-being of participated.
The significance of a knowledge of
Gilstrap et al. premature infants, The study was
Qualitative new organization in parents.
(2020) n = 14 nurses promoting care participation conducted in only one
the NICU for Nurses empower FCC.
USA Promote open hospital.
nursing. Managers encourage:
communication: simple There is no paternal
organizational structures,
language. perception.
more training resources.
Constant contact
Stay 24 h
The participants were
Heidari Understand the Only mothers Poor hospital facilities.
Qualitative women nurses.
et al. (2020) perception of nurses n = 18 nurses (not parents or Little staff to form FCC.
(six months It would be interesting
Iran about FCC in the n = 2 NICUS N-III. grandparents) Greater workload,
duration) to have more nurses
NICU. Training spaces parent dissatisfaction.
participate.
Nurse Training
FCC implementation on
NICU is determined:
Research nurses ‘and
-Cultural, legal and
physicians’ perspectives on Health policy and
Nursing perception operational challenges.
Mirlashari Qualitative n = 40 professionals implementing FCC in operational changes
understanding of Nurses and doctors are
et al. (2020) Thematic content n = 25 nurses the NICU: are required to
implementing FCC positioned
Iran analysis approach n = 15 neonatologists Imbalance of power implement FCC in
in the NICU. as leaders and
Psychosocial problems NICU.
facilitators of FCC
Structural limitation
implementation in
the NICUs.
Children 2021, 8, 35 13 of 19

The youngest (38.42%) and middle-aged (6.37%) healthcare professionals who par-
ticipated in the studies report that cultural differences or language barriers are diluted
through nurse–family participation in the NICU. This is due to the fact that the parents
observe the progress of the newborn through their participation in the care. Support
groups for parents are also promoted, where similar circumstances are addressed both in
pathologies and essential care for the upbringing of their children once they are discharged
from hospital [15,18,21].
In this sense, the information provided by quantitative studies [18,19] is relevant,
since they discover that the participation of parents within the NICU is necessary for the
development of newborn rearing skills. For such participation to occur, NICU nurses must
be up-to-date in care focused on the neonate–family binomial [19]. To further this finding,
a study conducted in Finland shows that well-trained nurses (n = 22 NICU nurses N-III)
facilitate the establishment of a family-centered culture of care [21]. Thus, from the point
of view of these professionals, the participation of parents within the NICU manages to
raise the quality of care, allows greater confidence in their professional role, and achieves
satisfaction with the work performed [20].
The qualitative study carried out by Toivonen [23] in which n = 51 professionals (n = 32
nurses and n = 19 medical managers) participated, shows that, with the participation of
parents in the NICU, they are the ones who manage to perform basic care that facilitates
the comfort of the newborn. This fact allows them to perceive the comfort of their newborn
and consequently reduce their level of stress, which is inherent in hospitalization [20]. In
this sense, it should be noted that parental participation modifies the nursing role because,
through the involvement of parents, an atmosphere of complicity with the nursing staff is
generated in the NICU. In this way, the nursing role goes from being an active caregiver to
a support facilitator for the newborn’s parents, an issue visible in the study carried out in
Finland [21].
The information provided by a qualitative study conducted in Iran in 2020 is worth
dwelling on [26]. This research affects the need for education and training of nursing
staff (n = 25) to carry out FCC. They even insist on training to carry out care with the
mother present, using the kangaroo method. Currently, health personnel (n = 40 nurses
and neonatologists) must provide instruction, training, and even teach parents of different
cultures, beliefs, and socio-cultural levels, while carrying out their care work.
However, it is interesting to highlight another qualitative study also conducted in Iran
in 2019 [25], (n = 120 nurses) that warns that parental involvement is not a new concept
in the field of newborn care, although this practice is being implemented ideally in many
countries [18,19]. Nevertheless, it is true that the study carried out in Iran [25] shows that
changes in the health policies of the center will be necessary if a hospital does not have
adequate resources that allow the development of a culture of care centered on the family.
This can translate into increased funding for increased staffing, NICU renovation, ongoing
staff training, and even parent accommodation.

3.3. NICU Nursing Training, Needs, and Experience

Of the 13 studies selected, nursing experience or specialization within the NICU
is reflected in nine (69.23%) of the studies reviewed, with a total sample of n = 1.346
nurses. Research has revealed that nurses must be trained to educate parents on the most
appropriate ways to care for their newborns. Care improves when it is offered by nursing
with more years of experience and better training. Thus, the research reviewed indicates
that n = 342 nurses have a range of work experience of 0–5 years. While n = 812 nurses
have an experience of 5–15 years, and n = 192 nurses are providing their services in the
NICU for a period longer than 15 years [15–17,20].
Therefore, the nursing group that has an average of 5–15 years worked (14.26%),
guarantees that the time factor is comparable with better training, which results in a higher
quality of patient care and interventions in the neonate without forgetting that new nurses
and those with less experience within the NICU also have training in FCC [15,16]. This
Children 2021, 8, 35 14 of 19

situation highlights the need to update knowledge with an FCC approach, which should be
mandatory within special services, involving the entire multidisciplinary team including
psychologists [17,20].
In this sense, an investigation carried out in Sweden in 2017 with n = 443 professionals
clarified that, for the medical profession, this participation gained importance as the FCC
culture was introduced in the NICU [18]. Therefore, according to this study, physicians
(n = 71) should also undergo FCC training periods in addition to n = 372 nurses. On the
other hand, an investigation reveals how the most experienced nursing personnel provide
care to the newborn from the first moment of their admission to the NICU, focusing their
attention on the neonate–family binomial, while the newer personnel focus their immediate
attention on the newborn despite having the necessary training in FCC [19].

3.4. Humanization of Care in NICU: Promotion of the Nurse-Family Relationship

Among the 13 documents selected to carry out this systematic review, there are
outstanding investigations focused on the humanization of care in the NICU. Specifically
in the USA, the studies carried out by Coasts [22] and Gilstrap [24] refer to the need for
n = 24 nurses to establish a positive relationship with parents, which makes it possible to
humanize the personnel–family relationship within the NICUs.
Through this mode of relationship, an atmosphere of cordiality is generated between
the nursing staff and the parents. Therefore, when delving into this sense, one of the
investigations [24] clarifies that, to establish this relationship with the parents, it is essential
to avoid the rotation of the personnel assigned to care for the newborn at least for a period
of six months. Thus, of the n = 14 nurses in the study, n = 10 (71.42%) had day shift,
n = 2 (14.28%) night shift, and n = 2 (14.28%) performed both shifts. It is appreciated that
unnecessary rotations can hinder the beginning of trust between the nursing staff and
the family. This being essential to start and maintain a positive nurse–family relationship.
Even the change of shifts (morning, afternoon, and night) can deteriorate a previously built
relationship between the nursing staff and the family.
In a qualitative study of n = 22 nurses, it is valued that humanized care is enhanced
when parents are allowed to spend more time in the NICUs [21]. This issue favors greater
participation in basic care and a close, more effective relationship with the nursing staff.
This relationship between nursing and family allows us to express the suffering and concern
accumulated by each of the members of the family unit [18,21]. In a study carried out in
Sweden [18] with a sample of n = 443 health professionals, of which n = 372 (83.97%) were
nurses, it can even be seen that the greater the experience of the health professionals within
these units, the greater the relationship with the family is promoted. On the other hand, the
study carried out in Finland [21] indicates that there is a greater understanding between the
more mature nurses and the family, achieving a pleasant and trusting atmosphere within
the NICUs. This promotes smooth communication with parents, even when their children
are admitted to intensive care [21]. This situation leads to positive feedback between staff
and family [18,21].
One of the research conducted in the USA in 2018 with n = 10 nurses states that the
FFC model promotes open and inclusive communication between nursing and the family.
The family gradually loses its fear of the newborn’s fragility [22]. This allows them to
receive real-time information about their child’s health status.
This mitigates their hopelessness and manages to humanize care within the unit [22].
It is also appropriate to clarify that nursing demands to be an active member of health
policies that promote the permanence of the family within the NICUs. Through the
FCC, parents are encouraged to participate in the care of their newborn. Even one of the
qualitative studies carried out in Finland in 2019 with a sample of n = 32 nurses involved
the family in carrying out basic tasks of caring for the newborn since, upon discharge from
the hospital, the parents will carry out such care at home [23].
However, not all nursing personnel (n = 42 nurses) are motivated to carry out their
work activity in the presence of the family within the NICU. On occasions, parents do not
Children 2021, 8, 35 15 of 19

stop asking questions, which prevents the performance of techniques between the staff and
even when it is vital to perform emergency care in a critical situation [22]. The influence
of the environment of these units must be taken into account. Even the stress that can be
generated among nurses and family members makes the communication strategies used
by these professionals very important, without forgetting that the number of newborns to
be cared for, their weeks of gestation, and the number of nurses within the unit and their
levels of experience will also have an influence [22,23].
Therefore, in relation to the humanization of care in the NICUs, some of the inves-
tigations warn that it is necessary to adapt to private spaces where parents can be alone
with their children [22,23]. This means adapting the units with spaces where information
can be transferred between professionals, in turn, equipped with technology that allows
continuous supervision and monitoring of the newborn as a safety tool. Which facilitates
the family privacy necessary to establish the parental role [23].
It is worth dwelling on the information provided by a study carried out in Ireland
in 2013, where the opinion of n = 250 nurses from seven hospitals was collected. They
considered that financial support to families is essential to implement the humanization of
newborn care. Because of the expenses that newborn care represents for the parents, their
travel to the hospital, personal hygiene, and maintenance during the admission of their
child can have an economic impact for families that is difficult to assume [14].
The n = 53 nurses, belonging to four NICUs (with care experience between 10–11 years)
who participated in the study carried out in Turkey in 2017, reported that to implement
the FCC model, the first point where the institution must intervene is with personnel, who
must be trained and motivated to develop their professional practice within these units.
The workload that professionals have within the unit in relation to the care of the newborn
will not be an obstacle, but it will be a driving factor to change the professional role for the
different levels that make up the units. A greater approach is even valued in nurses (with a
mean age of 32 years) who have their own family and descendants [19].

4. Discussion
The objective of this systematic review was to examine the perspective of healthcare
personnel in NICUs as facilitators of family empowerment. A total of 13 studies were
selected that met the inclusion criteria, which were conducted from 2013 to 2020. They were
diverse in their methodologies (quantitative and qualitative). The results obtained were
related to the perspective of the professionals in the administration of care, the need for
more specialized training within special units such as the NICUs, and the more humanized
contact between the professionals and the family.
In relation to the gender variable, the data showed that, at present, the presence of
females continues to be much higher than males in the nursing profession. In fact, some
studies value that the female nurse figure incorporates concepts such as participation and
negotiation to enhance family empowerment [4,6]. Nursing even covers the demands of
the family by including them in the care plan and detecting their needs [27].
The age variable reflected that the largest group is the one with more years of expe-
rience in complex units such as the NICU. Specifically, this group of nurses has an age
between 40 and 50 years. The results support that these years of care practice play a
crucial role in training parents as primary caregivers [28,29]. Curiously, it is found that the
newest nurses are those with the most university training, an issue that encourages family
participation, although it is true that since they do not have enough work experience, they
focus more on offering care technicians to the newborn [15–17,20].
However, in recent decades, a training process has been favoured for university grad-
uates, with a command of the scientific method and with a multi-professional approach,
which allows greater understanding, interpretation, and solution of the problems related
to their healthcare activity [23]. For its part, another study [28] considered that permanent
training and systematic updating of professionals within special units leads to the improve-
ment of job performance. This encourages professional improvement to develop through a
Children 2021, 8, 35 16 of 19

set of organizational forms that complement and enable the study and dissemination of
social, scientific, and technological advances that influence better healthcare [23].
In recent decades, there has been a movement to strengthen improvement in nursing,
recognized through the World Health Organization (WHO), which gives a strategic charac-
ter to its actions. This scenario allowed the emergence of postgraduate nursing programs in
different countries [30]. In fact, in Spain, one can speak of the specialty in pediatric nursing
through the internal resident nurse (EIR) system. In these studies, nurses received specific
training related to family involvement in neonatal care [20,26].
Therefore, the process by which nursing decides to specialize closely relates to Ben-
ner’s theoretical model, in which the process followed by a healthcare professional is
exposed until specialization in a specific area is reached [31]. This theory even shows how
nursing goes through a series of stages until reaching the expert level (beginner, advanced
beginner, competent nurse, efficient nurse, and expert nurse) [32].
In this sense, it is found that the expert nurse resolves critical situations, strives
to improve care, and promotes changes in daily routines, achieving patient and family
satisfaction [31–33]. It corresponds to the nurse involved in the formation of the family, as
it is an indispensable pillar for the care of the newborn [15–17]. In this way, parents become
protagonists of the care process, promoting much more active experiences [26,30,34]. This
philosophy considers that the nursing team in the NICUs must have an integrative vision
that combines scientific, technological, human, and emotional aspects, in continuous
evolution aimed at excellence in care [31,32].
Currently, there are numerous demands in Spain on the part of parents regarding the
extension of hours within the NICU. Even in 2013, an agreement was reached between the
Ministry of Health and the Autonomous Communities (CCAA) to promote the opening
of NICUs 24 h a day, although this situation in Spanish hospitals is not fully met [35].
Even though it is true that there is controversy among professionals, it is found in the
reviewed studies that healthcare professionals see it as adequate to provide support to
the family, but their desire not to involve them in care is also perceived [18–20]. However,
other studies affirmed that the professionals consider parental presence beneficial and
adequate, both for the neonate–family binomial and even for the nursing staff, reducing
their level of stress [21–23]. Nevertheless, the change that is taking place towards open-
door NICUs enables a transformation towards the humanization of care [36]. To provide
adequate care for the newborn and the family during hospitalization, it is necessary that
there be a good nurse–patient relationship, and an adequate number of them in work shifts
(morning, afternoon, and night). This even enhances the continuity of care by the same
professional, avoiding unnecessary shift rotations. These services guarantee the provision
of comprehensive and continuous care to the critically ill neonate [24,37,38]. Therefore,
nursing within the NICU must promote a new paradigm where holistic and global care
meets the needs of the newborn and the family, in one of the most critical moments after
birth [28,33,39,40].
Measures that can be applied in NICUs are proposed to enhance the humanization of
newborn and family care are as follows:
(1) Health policies should be promoted that allow hospitals to remain open 24 h, where
the family’s presence can be uninterrupted. This issue promotes their inclusion within
the healthcare team.
(2) Healthcare management should promote the inclusion of healthcare professionals
(nurses and doctors) with specific training in this type of unit and even promote
learning courses for new professionals who join these units and become part of the
multi-professional team. This situation would contribute within the NICUs to joint
participation of the multidisciplinary team and the family.
(3) The humanization within the NICUs should be addressed from the beginning by the
professionals themselves, encouraging parental participation and giving meaning to
the experiences of families. This situation can be carried out through the management
area, respecting the shifts of the nursing that is found in these units.
Children 2021, 8, 35 17 of 19

5. Conclusions
Advances in hospital care have led to a new paradigm in the way of caring, in which
the parents’ involvement in care and their permanent presence during medical and nursing
procedures is considered beneficial for both the family and the newborn. This situation
implies the need to establish individual rooms, each one with a bed, to offer the family
rest. A common room for families is also promoted, which encourages the relationship
between different families. In addition, this space is usually equipped for use during meals.
Thus, for these families, the hospital stay can be maintained over time due to the economic
savings that these measures represent.
However, there is still no general vision to apply this new way of working where the
presence of parents is formalized 24 h a day. More training would be necessary for both the
healthcare personnel and the family itself. Even health policies, such as health managers,
should include improvements regarding space and trained personnel in these units. In
addition, the presence of an intermediate command 24 h a day would be necessary to
coordinate the health personnel with a unified turnaround where the routines facilitate the
care of a neonate in a critical situation.
Therefore, it is verified that the patient and his/her family are recognized as the focus
of attention. That nurses and doctors, as well as other professionals of the health team,
must actively participate in humanized care. In addition, the patient and her/his family
must be included in decision-making, and may even discuss the daily care plan and the
expected results. This issue enhances family participation in the continuity of care when
they are applied by the same professionals in their corresponding shifts within the NICUs.
Even these professionals know the preferences of the newborn and the family for greater
involvement in care. Therefore, care centered on the family and the newborn becomes safer,
more efficient, effective, and timely.

Author Contributions: Conceptualization, S.G.-C., I.G.-V., and M.D.-A.; methodology, I.G.-V., B.Y.-
A., E.M.-M., and B.M.G.; formal analysis, B.Y.-A., E.M.-M., and M.D.-A.; investigation, S.G.-C., I.G.-V.,
B.M.G., E.M.-M., and B.Y.-A.; writing—original draft preparation, S.G.-C. and I.G.-V.; writing—review
and editing, B.M.G., M.D.-A., and E.M.-M.; supervision, I.G.-V.; project administration, S.G.-C. and
I.G.-V.; funding acquisition, S.G.-C. and B.M.G. All authors have read and agreed to the published
version of the manuscript.
Funding: The ENDOCU Research Group, 2020-GRIN-29236 (Nursing, Pain, and Care), co-financed
with European Regional Development Funds (ERDF) in the resolution of 19 February 2020 (DOCM
26 February 2020), of the University of Castilla-La Mancha, has subsidized this research.
Acknowledgments: We thank the staff of the Library of the University of Castilla-La Mancha, the
Toledo campus (Arms Factory), for their invaluable assistance in collecting full-text articles.
Conflicts of Interest: The authors declare no conflict of interest.

Abbreviations

NICU neonatal intensive care unit

PICU pediatric intensive care unit
NB newborn
FCC family-centered care
NIDCAP newborn individualized developmental care and assessment program
WHO World Health Organization
HQ high quality
MQ medium quality
LQ low quality
Children 2021, 8, 35 18 of 19

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