Problem

Overall babies admitted to neonatal units in the United Kingdom receive a high standard of clinical care. However, less consistent attention is paid by neonatal staff to communication. A lack of regular and informative communication from neonatal staff is the most common underlying reason for parental complaint in our neonatal unit. Having your baby admitted to a neonatal unit is often sudden and unexpected, and a time of great stress and uncertainty. Therefore, frequent and sensitive communication from neonatal staff is important to help alleviate this stress and ensures parents understand their baby's condition and progress. Good communication also empowers and involves parents in their baby's care and is essential in providing family centred care.

The aim of this project is to assess whether the implementation of a communication tool named the baby diary will improve parent-staff communication in our neonatal unit and enhance the parental experience of neonatal care.

Background

Over the last decade a number of projects have been performed reviewing communication and parental satisfaction in neonatal units in the United Kingdom and have subsequently highlighted areas for improvement. The Department of Health in 2009 and NICE in 2010 developed quality standards for specialist neonatal care which focused on communication and the family experience.[1,2] Evidence suggests that improving the quality and quantity of communication between parents and neonatal staff benefits patient care, promotes positive parent-child interaction and improves overall family well-being and satisfaction.[3,4] A summary of research results and recommendations from 'The POPPY Project Steering Group' published in 2009 [5] highlighted the importance of providing family centred care in all neonatal units and focusing on good communication to empower and involve parents. Good communication encompasses clear and frequent information sharing, active listening in order to address parental concerns and questions and indirectly involves providing emotional support and encouragement.

The Picker Institute [6] performed a national survey on parents' experiences of neonatal care in 2011 which on a national level highlighted that 65% of parents said they were not able to speak to a doctor about their baby as much as they wanted, and only 55% agreed that staff always included them in discussions about their baby's care. The results specific to Croydon University Hospital showed that their overall performance was worse than the national benchmark, especially in parents' response to the question asking whether parents were given regular consistent information about their baby's condition (among the worst 20% of units nationally). This report highlighted that there is definite scope for improving the standard of communication between parents and staff in our neonatal unit but also at a greater national level.

Baseline measurement

The study design was a questionnaire assessment based on the Department of Health [1] and the National Institute for Health and Care Excellence (NICE) [2] quality standards for specialist neonatal care. Parents or carers of babies on the neonatal unit were invited to complete a confidential questionnaire to assess their level of satisfaction with communication from neonatal staff and to identify how current practice can be improved.

The retrospective parental satisfaction questionnaire consisted of five yes or no questions and was given out on the day of discharge over a ten week period (n=44, response rate 57%). The questionnaire results showed that the Department of Health and NICE quality standards on communication and parental involvement were not being met in our neonatal unit as only one out of five questionnaire questions received a hundred percent yes-response by parents. The questionnaire highlighted parental dissatisfaction with the quantity and quality of communication which echoes the results from the 2011 Picker survey.[6]

See supplementary file: ds4697.ppt - “Example pages from our diary”

Design

Reviewing the initial data, it became clear that a simple and cost effective communication tool was needed to improve both the quantity and quality of parent-staff communication and encourage parental involvement. The tool designed was the creation of individual baby communication diaries. The diary was intended to act as an aid to improve communication to parents and complement face-to face communication. The diary aims to achieve this by providing brief and regular bursts of information as well as provide a space for parental reflection and questions. It also acts as a keepsake of their baby's journey through the neonatal unit.

The diary's effectiveness relies on multidisciplinary input and involvement from doctors, nurses, and parents. The communication diary is distributed to each baby on admission to the unit with an accompanying leaflet to parents explaining its use. The diary is attached in a folder to the baby's incubator or cot so it is easily accessible by staff and parents. Doctors and nurses write in updates about the baby's progress and well being and about staff and/or parents' interaction with their baby and parents write in memories or notes as well as questions or concerns for staff to address during face to face communication.

Our diary had to be simple yet effective as we only had a budget of a hundred pounds per year which was kindly donated by The Friends of Croydon University Hospital Charity. The diary was created by the project leaders and consisted of a cover made out of decorated coloured card and an insert of printed A4 sheets of white paper which were all folded and stapled together to form a booklet. The layout of the diary consists of space on admission to glue in a photograph (printed in our unit) with space to write in baby's details (name, gestation, weight etc.) as well as family members' names and space on discharge for a photograph and discharge details. In between, the diary consists of pages to write in which are divided into two sections; a section entitled 'My Baby's Journey' for updates and comments by staff as well as parents and a section entitled 'My family's notes, memories and questions' for parents and other family members to write in. The format and layout of the diary in this project is completely flexible and can be created and its use be adapted as per each individual unit's wishes and criteria as it is the concept along with multidisciplinary input and good implementation that makes the diary an effective tool. Please see the attached file for page examples from our diary to complement understanding of our format.

Throughout the two month implementation process and on follow up 15 months later, we continuously asked users (including parents and all members of staff on the neonatal unit) for feedback on how to improve the diary. The overall concept stayed the same but minor adjustments were made to the layout. This included removing the separate doctor and nurses' sections and changing the day by day format so that the diary became more flexible and adaptable to the varying intensities of the neonatal unit environment. Additionally, rules and regulations surrounding documentation by staff were more clearly defined and approval by the legal team obtained.

Strategy

The communication diary concept was created by the project leaders following analysis of the questionnaire results and implemented over a two month period after multi-disciplinary input and discussion from staff and parents.

The first step after creation of the first draft of the diary was presenting the data and the suggested intervention at our neonatal clinical governance meeting. The overall feedback was positive and consensus was to trial implementation under two conditions. Firstly, that we ensured clear rules were written on who and what can be written in the diary, and secondly that we ensured we made it clear to staff and parents that it was to complement and not replace face to face communication. As a result of this meeting, clear instructions for staff were written, approved by management, and distributed to all staff. A parent information leaflet was written stating the aim and use of the diary. The staff instructions state that only fully registered and permanent doctor or nursing staff can write in the diaries, that senior supervision should be sought when writing a strictly "medical" update, and to not mention diagnoses if not mentioned prior to verbal comments, results, or timelines in the updates. It also states that the diary should only be used for simple, one to two sentence updates without using medical jargon, and that if a longer discussion is needed then one can draw parents' attention to the need for face to face communication in the diary.

The diary was then trialled in the unit for a two week period and minor adjustments were made. The main feedback was that parents and nursing staff wanted more space to write and so the layout was adjusted accordingly.

We then had a final meeting with all neonatal staff to review the practicalities, explain the most up to date diary format, and encourage enthusiasm among and participation from all staff. Written information in the form of leaflets and posters and the latest version of the diary were also re-distributed to staff to ensure uniform understanding and maximal participation. Parents received an information leaflet introducing the use of the diaries and staff re-iterated the diary's use on their baby's admission to the unit.

The process from creation to implementation of our intervention took two months. After successful implementation, the project management was handed over to the unit manager and two senior staff nurses to ensure longevity of the diaries and ongoing development and the production of the diaries was kindly taken up by two health care assistants.

Results

To assess whether the baby diary was an effective communication tool to improve parent-staff communication and parental satisfaction in our unit, the same five question parent questionnaire was repeated on two occasions post implementation of the diary in March 2013. The first occasion was one month post implementation over an eight week period (1/4-26/5/2013) with a response rate of 23% (n=17) and then again 15 months post implementation over an eight week period (23/6-17/8/2014) with a response rate of 65% (n=44).

There was a clear and demonstrable improvement regarding parental satisfaction with communication and involvement on both occasions in comparison to initial results. More parents in the post-intervention cohort felt they were receiving regular communication from staff (94% - one month and 93% - 15 months post implementation) and felt that their questions and concerns were being addressed (100% - one month and 93% - 15 months post implementation) than in the pre-intervention cohort (77% and 91% respectively). Furthermore, a 100% percent of parents felt they understood why their baby was admitted to the unit (100% in pre intervention cohort) and a 100% percent of parents (86% in pre intervention cohort) were updated by a senior member of staff within 24 hours of admission. Also parents felt more involved in their baby's care in the post intervention cohort (92% - one month and 100% - 15 months post implementation) in comparison to 88% of parents in the pre-intervention cohort. Please see the supplementary file for a comparative table of results for the five questions asked before and after the implementation of the communication diary.

In addition, 100% of parents said they liked reading the diary, 94% felt it added to their understanding of how their baby was doing and a 100% understood the comments made by staff. A hundred percent of parents found a diary by their baby's incubator or cot confirming good implementation. However, only 81% of parents said that a member of the neonatal staff wrote in the diary four or more times a week and only 32% percent of parents wrote in the diary themselves.

Not only do these results reflect the primary positive impact of the diary improving communication, but achieved a secondary effect. This project highlighted to all staff the importance of communication, and the dairy acted as a daily reminder on the ward round to review whether parents would wish or benefit from a face to face update.

See supplementary file: ds4698.ppt - “A Comparative table of questionnaire results”

Lessons and limitations

The first lesson learnt is the importance of having multi-disciplinary expertise and involvement when implementing an intervention in a department. Multi-disciplinary commitment was essential in every step of this project. Having all members of staff and parents involved was key in successfully assessing the problem, providing feedback on the intervention prior and during implementation, as well as achieving effective implementation and continuity. Changing the culture around communication takes time to put into practice and getting all members of staff and the parents involved continues to be a challenge.

As you can see from the data above, even 15 months post implementation not all staff are regularly documenting in the diary and only a third of parents are writing in the diary. However, 100% of parents were given a diary showing that it is sustainable and has great potential for longevity. The regularity of staff documentation is affected by staffing levels, frequently changing members of staff and the overall intensity of work and number of babies in the unit which are all factors that are difficult to control. Parental participation with our multi-cultural patient population is affected by language and cultural barriers and also different parental coping techniques. The language barrier could be improved by translating diary entries into different languages using online translation tools. Further encouragement and continued staff training along with positive feedback from users and external reviewers shall hopefully continue the positive change that is occurring.

The difficulty surrounding the use of questionnaire based assessments has also been raised, including obstacles with distribution and parental participation. With the aim of minimising limitations encountered in this project, one would spend more time engaging all staff to encourage widespread distribution and spend more time informing parents of the aims of the questionnaire. Our response rate one month post implementation was impacted by lack of staff encouragement resulting from new untrained staff and the patient population at the time consisting of a large proportion of short stay patient (<48 hours) for which the diary could potentially play a less important role. Also, in view of our multi-cultural patient population we translated the questionnaire on second re-assessment into different languages which improved parental participation and response rates.

Conclusion

The baby diary is a simple, practical, and cost-effective tool to enhance communication between parents and staff in the neonatal unit. The diary also encourages family involvement and helps provide family centred care in the neonatal unit. Our project demonstrates an improvement in parents' satisfaction with communication following the successful implementation of individual baby diaries. However, ongoing effort needs to be made to ensure continuity and multidisciplinary involvement. It should also be emphasised that the diary should only be used as a communication aid and continuing attention needs to be paid to ensure and improve frequent face to face communication with parents.

This project since implementation in March 2013 has been accepted by the Bliss Charity into their Best Practice Bank [7], was positively mentioned in the Croydon university Hospital Care Quality Commission Report [8], and is under review for use by the Picker Institute.

References

1. Department of Health, Toolkit for High-Quality Neonatal Services 2009, Principle 3: Care of the baby and family experience.

2. NICE, Quality standard for specialist neonatal care 2010, Quality Statement No 5.

3. Weiss S, Goldlust E, Vaucher YE. Improving parent satisfaction: an intervention to increase neonatal parent-provider communication. J Perinatol 2010 June;30(6):425–30.

4. McCormick MC, Escobar GJ, Zheng Z, Richardson DK. Factors influencing parental satisfaction with neonatal intensive care among the families of moderately premature infants. Pediatrics 2008;121:1111–8.

5. POPPY Steering Group. Family-centred care in neonatal units. A summary of research results and recommendations from the POPPY project. London: NCT; 2009.

6. Picker Institute Europe. Parents’ experiences of neonatal care: a report on the findings from a national survey' (November 2011).

7. Bliss-sharing good practice: Improving communication between parents and healthcare professionals. Best Practice Bank. E-newsletter. 6th of June. http://www.bliss.org.uk/wp-content/uploads/2014/05/Best-practice-bank-baby-diaries-a-tool-to-improve-communication-Croydon-University-Hosital2.pdf

8. Croydon University Hospital Care Quality Commission Report 2013. http://www.cqc.org.uk/sites/default/files/new_reports/AAAA0782.pdf, Page 35

Declaration of interests

None declared.

Acknowledgements

Sophie Bertaud, Samantha Nailor, and Grant Marais as well as all members of staff and parents involved in the project at Croydon University Hospital for their support.