Effects of single family room architecture on parent–infant closeness and family centered care in neonatal environments—a single-center pre–post study

Historically, neonatal intensive care has used open nurseries to enable staff monitoring of multiple infants, but these layouts limit parental presence and privacy. Recognition of the importance of parents as primary caregivers and the need for less stressful environments has driven a shift to single family room NICUs (SFR-NICUs). Prior studies suggest SFR-NICUs increase parental time and involvement, enhance bonding and parent–infant interactions, and are associated with improved infant outcomes. However, evidence on SFR-NICUs’ effects on parents’ experiences of family centered care (FCC) is mixed; while intimacy and involvement may improve, parents can feel isolated and less connected to staff and peers. Because FCC depends on both environment and care culture, evaluating the impact of architecture within a single unit before and after a move can clarify architecture’s role. This study assessed whether moving to an SFR-NICU increases parents’ presence and SSC and improves parents’ experiences of FCC.

Prior work reports increased parental time and involvement in SFR-NICUs and associations with better infant outcomes (e.g., weight gain, lower morbidity, improved breastfeeding, and neurodevelopment). Parents’ presence can reduce infant stress at term-equivalent age. However, parents in SFRs may face challenges with communication and connection to staff, decision-making involvement, and peer support, potentially leading to feelings of isolation. Comparative studies across units confound architecture with care culture; some show more SSC and parental presence where overnight accommodations exist. Other studies found no difference in SSC between open-bay and single rooms when units strongly promote SSC. Educational interventions (e.g., Close Collaboration with Parents) can enhance FCC irrespective of architecture, suggesting care culture may be a dominant factor. Key gaps include the specific effect of architectural change on SSC and FCC ratings within the same unit and staff.

Design: Single-center pre–post study conducted before and after an architectural change from shared patient rooms (2–4 patients/room, no overnight parental facilities) to an SFR-NICU (11 single family rooms with parent beds; additional shared rooms used when SFRs were full). The unit moved to the SFR layout in April 2014; data collection occurred in two periods: September 2013–March 2014 (shared rooms) and April 2018–February 2019 (SFR-NICU). Care policies and FCC culture remained similar; staff had previously completed the Close Collaboration with Parents training. Setting and participants: Turku University Hospital NICU (level III). Inclusion: parents of preterm infants <35 weeks’ gestation, recruited within 6 days of birth. Exclusions: anticipated hospitalization <3 days, triplets or more, lack of fluent Finnish, critical condition with uncertain survival. Target sample: 30 families per period. Enrolled: 31 families pre-move; 30 families post-move. Unit characteristics: Staffing and supports were similar across periods; SFR-NICU provided enhanced parental facilities (beds, lounge, kitchen). Visitation policies for significant others remained unchanged. Monthly workload was calculated as weighted patient days (high-intensity×3, medium×2, observation×1). Measures: - Parent–infant closeness: Parent-Infant Closeness Diary, completed daily for 2 weeks post-recruitment or until discharge, recording in 5-minute intervals parental presence in NICU and SSC duration (infant on parent’s bare chest, diaper only). - Quality of FCC: Digital Family Centered Care–Parent Version (DigiFCC-P), one SMS question nightly in random order across nine FCC domains (active listening, participation in infant care, individualized parent education, participation in decision-making, trust in staff, staff trust in parent, involvement in medical rounds, individualized information, emotional support). Responses on 7-point Likert scale; 0 indicated parent not present that day. One reminder sent if no response. For twins, parents rated FCC as a mean across infants. - Background factors: Infant (gestational age, birth anthropometrics, sex, mode of delivery, singleton/twin, length of stay). Parent (age, education, occupation/socioeconomic status, smoking, time of first interaction, distance home–hospital, relationship status, siblings at home). Unit characteristics from head neonatologist survey. Ethics: Approved by Hospital District of Southwest Finland Ethics Committee (62/1802/2013, 08/011/18). Written informed consent obtained. Statistics: Group comparisons used Fisher’s exact test (categorical), Student’s t-test (normally distributed), and Wilcoxon rank-sum test (nonparametric). Monthly workload correlations with FCC used Pearson’s correlation. ANCOVA compared median daily durations of presence and SSC between environments, controlling for parent education, singleton/twin status, relationship status, siblings at home, and home–hospital distance. Durations were square-root transformed to meet normality assumptions; untransformed changes reported relative to median durations in shared rooms. ANCOVA also assessed differences in average FCC scores, controlling for parent education, singleton/twin, and relationship. Analyses used SPSS 25 and SAS 9.4.

Sample and baseline: 31 families (shared rooms) and 30 families (SFR-NICU) participated. Infant background characteristics were similar across periods. Parental education was higher in the SFR cohort (mothers p=0.006; fathers p=0.004). Parental presence: Either parent’s median daily presence increased from 5.9 h (IQR 4.9–7.6) to 10.2 h (IQR 7.6–13.2). Daytime (8 a.m.–8 p.m.) presence increased by a mean 1.7 h; nighttime (8 p.m.–8 a.m.) by a mean 1.7 h. Mothers’ presence increased from median 5.2 to 9.1 h/day; fathers’ from 3.6 to 5.9 h/day. Adjusted ANCOVA estimates: +3.9 h for either parent (p<0.0001), +3.5 h for mothers (p<0.0001), +2.3 h for fathers (p=0.0069). Skin-to-skin contact (SSC): No statistically significant differences. Total SSC per infant: median 3.0 h/day pre-move vs 4.1 h/day post-move. Mother–infant SSC: 2.0→2.4 h/day; father–infant SSC: 1.0→1.5 h/day. Background factors: Siblings at home reduced mothers’ presence by 1.25 h/day (p=0.04) and fathers’ by 1.49 h/day (p=0.01). Mother–infant SSC was not affected by background variables. Father–infant SSC decreased by 0.12 h/week with increasing gestational age (p=0.02) and by 1.2 h if the infant was a twin (p=0.002). Total SSC per infant increased by 1.4 h if the infant was a twin (p=0.04). FCC experiences: Parents rated FCC highly in both architectures with no significant differences. Mothers’ total FCC mean: 5.97±0.59 (SFR) vs 6.15±0.51 (shared rooms) (p=0.27; adjusted p=0.19). Fathers’ total FCC mean: 5.86±0.61 (SFR) vs 5.73±0.81 (shared rooms) (p=0.88; adjusted p=0.33). Lowest-rated elements in both settings were participation in medical rounds, emotional support, and participation in infant care. Workload: Mean monthly weighted patient days: 898.0 (shared rooms) vs 849.4 (SFR), not significantly different (p=0.38). Monthly workload did not correlate with FCC ratings (mothers p=0.23; fathers p=0.97). Additional associations: Lower maternal education associated with higher overall FCC rating (p=0.04), better ratings for individualized education (p=0.04), and information provision (p=0.02). Mothers of twins reported more individualized information (p=0.02). Maternal participation in medical rounds increased with higher gestational age (p=0.03).

The architectural change to an SFR-NICU substantially increased parents’ presence, addressing a key goal of family-centered neonatal care, yet did not increase SSC duration when baseline SSC was already relatively high. This suggests that architectural privacy and overnight accommodations enhance availability but that sustained SSC may depend more on care practices and active encouragement than room type. The lack of improvement in FCC ratings likely reflects a ceiling effect due to an already robust FCC culture established by prior staff training and the relatively private shared-room design before the move. Persistently lower ratings for emotional support and participation in medical rounds indicate ongoing challenges in these FCC domains despite increased opportunities for parent–staff interaction in SFRs. Background factors influenced both presence and experiences: siblings at home constrained presence; higher gestational age related to greater involvement; and higher parental education correlated with more critical assessments, highlighting the need for individualized support. Overall, within a consistent care culture, architecture primarily boosted presence rather than altering SSC or perceived FCC quality.

Moving to an SFR-NICU nearly doubled parents’ daily presence but did not increase SSC or improve already high FCC ratings. The findings underscore that while architecture can facilitate parental availability, enhancements in SSC and FCC may require targeted practice changes focusing on emotional support and integrating parents into medical rounds. Future research should develop and test strategies to strengthen these FCC components and explore automated, objective tools to measure parent–infant closeness.

Single-center pre–post design with relatively small sample sizes and only nine families with extremely preterm infants limits generalizability, particularly to the most immature infants. The DigiFCC-P showed a ceiling effect, potentially obscuring improvements in FCC. Diary-based recording of presence and SSC may underestimate durations due to participant burden. Although care culture and staffing were largely consistent across periods, unmeasured temporal changes cannot be fully excluded.