Designing for family engagement in neonatal ICUs: How is the interior design of single-family rooms supporting family behaviors, from passive to active?

Why does it matter?
While family members are involved in care for all types of patients, they often have an especially active caregiving role in the NICU. There are four types of family behavior cited in previous research around family presence in the NICU, ranging from the passive end of the spectrum, including family presence and family care (that is, care for families), to more active family information exchanges and family care-giving to the infant. The time parents spend in the NICU environment is critical to their learning process as they prepare to take their babies home after discharge. As the trend in NICU design has moved to primarily single-family rooms, it is important to understand how this environment and specific aspects of these rooms influence the process of Family Engagement.

How was the study done?
Data collection took place in single family rooms at two separate Level III NICUs. In the first case (Case 1) the rooms were approximately 190 square feet and no private bathroom and no exterior window. In the second case (Case II) the rooms were roughly 350 square feet with private bathrooms in the room, solid sliding partitions between the infant care and family zones, as well as exterior windows in the family zone and bathrooms. Researchers used a qualitative approach which included 50 30-minute interviews with family and staff, 214 hours of observation of family and staff members, as well as evaluation of built environment characteristics.

So what do we learn from the study?
Machry and colleagues found that family behavior generally falls into three categories.

The first behavior category was homelike behavior. Families and staff on both units described the rooms as “home-like” or “homey”. They described the bathrooms, storage, decorations, and other design features as “their own”. Behaviors mirrored common activities new parents do at home, like taking care of children and receiving help and support from family and friends. These behaviors were highly reliant on the positioning of the furniture and elements such as partitions that could be closed so that parents could sleep, pump, or cry privately in the family zone. Families in Case 1 had many comments related to the challenges of having no private family bathroom, which was especially challenging for recently postpartum mothers.
  
The second behavior category identified in the research was educational and collaborative behavior, which took place in both the single family room and the nearby corridors. Behaviors included talking to staff, looking up information, or receiving education from staff. Family members were often in the family chair, near information boards, the infant bed/incubator, or the bedside computer workstation where staff updated the patient’s chart. In the Case 1 NICU, staff commented on how a lack of storage contributed to clutter on the furniture, which made it challenging to sit and have eye-to-eye level conversations with families.
  
The third behavior that emerged in the data was infant care. Chairs seemed to be the primary physical element to support this behavior, with chairs being moved close to the infant bed for care, and oriented towards information boards and monitors. On the other hand, the ability to take a break away from the infant care area in order to rest and recharge was highly important. Positive distractions in the family zone were key elements to support taking a break, such as window views, artwork, and TV, which were not available in Case 1.

Can we say the results are definitive?
Let’s talk about limitations. The authors acknowledge this study had a small sample and data was only collected over a short time period. However, this was designed as a qualitative study with exploratory, rooted in natural inquiry, and so a small sample size is perfectly appropriate. The findings – which, as the authors describe as “bound to participants’ worldviews and experiences within the context of their unique health system and geographic locations” – provide a valuable contribution for future research to build on.

What’s the takeaway
Findings highlight the importance of the physical environment to support family engagement behaviors. The authors discuss the importance of thinking of “work as done” – or, simply, the real-life in-situ chaos of NICU life – And it is important to acknowledge that “work as done” in the NICU is not just work done by staff (as it is in other healthcare environments). Work as done in the NICU includes family members who are working too. The affordances provided by the private bathroom and sliding partitions in Case 2 seemed especially important to give parents the homelike breaks they needed from work, due to the option for privacy, positive distractions, and comfort, without leaving the room, so that eventually they would be able to leave the room, to go home.
 

Summary of:

Machry, H., Joseph, A., White, R., & Allison, D. (2023). Designing for family engagement in neonatal ICUs: How is the interior design of single-family rooms supporting family behaviors, from passive to active? HERD: Health Environments Research & Design Journal, in press. https://doi.org/10.1177/19375867231168651

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