The participants of the study identified guidance by the mentors and other experiential learning methods as the main facilitators of the Close Collaboration with Parents Training Program. In addition to the facilitation process, other key elements affecting the implementation were the characteristics of the innovation and its observable benefits; elements concerning the recipients, such as motivation and commitment; and contextual elements, such as support from the leadership, timing, and unit design. Four main themes and 10 subthemes interrelated and influenced each other and either promoted or hindered the implementation (Fig. 1). Findings are organized according to the time order of the implementation progress.
Context/timing
The unit leadership decided to initiate the training program. Both the nurses and managers commented that the mental preparation for the training and for the changes the training program aimed at was important for the implementation. One of the managers said about timing: “We had time to psychologically prepare for it [training program] and then we had everything ready for this training” (Managers group a). In addition, the identified need for a change in care practices to involve parents more in infant daily care promoted the implementation, as two of the managers said: “We know the practice will be different when we move to the new hospital [with single family rooms], and because of that we had to change our care culture” (Managers group d). On the other hand, the staff who had no time to prepare for the training felt that it started too quickly, which made the implementation more difficult. “Our highest leadership just informed that now we start. We should have done it more systematically” (Managers group g).
Innovation/the nature of the training program
Both managers and nurses mentioned receiving inadequate initial information about the goals and schedules as a weakness of the training program. It was not until during phase 2 or 3 that they understood how the knowledge of infant observations related to the final goal of the training. “Our mentor nurses didn’t get a good view of the program as a whole when it started. They only got some crumbs of information” (Managers’ group g). Some of the staff wished that the training phases had been introduced in shorter time intervals.
Recipients/change in professional role
The units decided to allow parents’ presence without time limitations after preparation, at the beginning of structured training. Some comments from the managers and nurses indicated that this change caused resistance in some of the nurses. “I remember that at first some of the nurses said that they will leave. They couldn’t cope with taking care of parents. I think it was because we are used to working routinely and doing the intensive care” (Nurses’ group a). Participants stated that some nurses were uncomfortable with continuous parental presence at the beginning of the program. They described the feeling that nurses were not needed anymore and of losing their authority. “First there was a fear that nurses are not needed anymore, but I have not heard those kinds of comments anymore” (Managers’ group h). They also identified that parental involvement required a change in the nurses’ professional role, which, at first, was seen as difficult. However, the nurses described that they gradually adopted their new role as the parents’ facilitators instead of performing the care by themselves. “After the training program the nurses’ professional role had changed. I think there is some insecurity about one’s own role regarding the infants’ care” (Nurses’ group a).
Facilitation/guidance from the mentors
Two to four mentor nurses implemented the training program in their own unit. Participants emphasized the crucial contribution of the mentor nurses in the progress of the training program and in the changes in care culture. “Our mentor nurses were motivated. We had a certain resistance here, but nurses anyway gave feedback that their way of working is changing and that parents are more involved” (Managers’ group g). “Well, our mentor nurses deserve the credit for that. They have given 110% of themselves for the training” (Mangers’ group f). According to the nurses’ and managers’ descriptions, successful mentor nurses were committed, motivated, empathetic, and good communicators. They did not provoke strong or negative emotions, and they had confidence in doing pair practices with colleagues who were more experienced than themselves. “Our mentor nurses were persons who didn’t stir strong emotions among the work community, and they had a good grip on the training” (Managers’ group h). On the other hand, the mentor nurses who did not give space to the staff they were training and who did not respect the individual pace and learning ability of their colleagues made mentoring and the implementation of the new care practice difficult. The participants pointed out that the characteristics of a good mentor nurse should be carefully considered when the mentors are chosen. “Sometimes bad mentoring might spoil a good thing. It’s really important that the right persons are chosen as mentor nurses” (Nurses’ group b).
Innovation/observable benefits for families and staff
The staff perceived that the changes in FCC practice were beneficial for infants, parents, and staff alike. That feedback motivated the staff to continue the implementation. Nurses perceived that parents’ increased presence made them more confident in caring for their infant. Closer relationships with parents and increased parent involvement resulted in the transition to home becoming smoother for both the parents and the staff. “I don’t feel nervous anymore when I discharge the baby, because I know that parents can manage” (Nurses’ group d). From the doctors’ point of view, the parents made a valuable contribution to their work by knowing their infant well and reporting their observations so they could be used in medical decision-making. “I get most of the information about the infants’ condition from their parents now and I have noticed that they can give me really valuable information. It’s possible because they are present all the time” (Managers’ group f).
Participants stated that the training program improved interactions among staff and helped them harmonize care practices. This led to better work satisfaction, as reported by both the managers and the nurses. They also reported that the well-being of the parents and infants was improved. “Feedback from the parents is like a reward for nurses. They see how good the baby and parents have it together” (Managers’ group d).
Recipients/staff motivation
Nurses’ attitudes toward parents became more positive with sustained training. In addition, the staff stated that they had begun to appreciate parents’ presence. “Our attitude is influencing everything, and that attitude is more permissive now” (Nurses’ group b). After the training, the nurses perceived parents as more of a resource than a burden in caring for the infants. “Our attitude has turned to such that we want parents to be here” (Nurses’ group h). A few comments revealed that the depth and scope of the new attitudes toward parents varied among the units. “We have really made progress, but it takes time to fully adopt this” (Nurses’ group g). “It is not good if mother stays overnight and then she is too tired to take care of her baby. We have a rule that a mother can stay overnight if she nurses the baby herself” (Nurses’ group g).
There were differences in adopting the new practice among the nurses. Staff perceived that newly graduated nurses had fewer difficulties in adopting the new care practice because they were not as used to the old one. Some of the nurses who had more work experience felt they occasionally missed the old care practice, especially when the unit was busy and there were a lot of parents. “Sometimes I wish that parents could visit behind the window. I have experienced that wonderful time, when I got to take care of the infant myself” (Nurses’ group b). However, some experienced nurses expressed relief at receiving permission to encourage the parents to participate. They had already felt before the training program that parents should not be separated from their infants. “I don’t have to feel like I’m too kind or soft anymore when everyone has the same agenda” (Nurses’ group d).
Recipients/change in professional role
All the interviewed nurses were aware that to ensure implementation, parents’ participation should be voluntary and that every family should decide themselves how much they would attend. “We have to take into account the situation of the family” (Nurses’ group d). Participants revealed that some parents signaled insecurity about their role and about how much time they should spend in the unit. Nurses stated that they wanted to be sensitive to parents’ needs, avoiding burdening them with too much responsibility. “We have to avoid exhausting parents with too much responsibility” (Nurses’ group h). It was clear to the nurses that they carried the main responsibility for the infants’ medical care, together with the doctors. Staff recognized that the parents needed support and encouragement to find their role. “We still represent authority for parents, and if we tell them what to do, they try to do so. We have to encourage them to do what is best for their family” (Managers’ group h).
Innovation/the nature of the training program
The training program progressed slowly, which was seen as beneficial by both the managers and nurses. The adaptability and clear structure were also named as strengths of the training program. The program was integrated into the existing practices, and the staff decided themselves how to implement practical changes instead of copying practices from the unit in which the program was developed. Participants stated that the training program provided an analytical way to evaluate the existing practice, thus facilitating the process of learning and moving away from the old practice toward more FCC. “Family-centered thinking has increased and the whole family is now in the focus, not only the infant” (Managers’ group a). Various tools used in the training were experienced as helpful to involve the parents in caretaking and to recognize the individual needs of the families. “I think we have got really good tools and by using them we can learn to know the families” (Nurses’ group h).
Facilitation/experiential learning
Experiential learning methods including theoretical teaching, joint observations of infant behavior, and reflections with mentor nurses helped the nurses to recognize the individual needs of infants and to understand the influence of their care on the infants’ behaviors. “Observing infant behavior was really educational. I learned to watch for different things than before” (Nurses’ group b). “Discussions with the mentor nurse after observations were good” (Nurses’ group d).
In addition to the discussions with mentor nurses, the interactions among staff also seemed to be important for the implementation. In the units in which the participants stated they had discussed the training program and changes in care practices together, the changes in care culture were found to be more consistent. In the units in which the staff did not agree on changes in care practices, there were more difficulties in implementation. “We don’t have a uniform approach for care and there should be. You can’t do this job as you like, but we must have the same approach” (Nurses’ group b).
Context/support from the leadership
Nurses and managers expressed that support from the leadership formed the basis for the implementation of the training program. “In the beginning, we made a common decision that everyone will do their best and all resources that are needed will be given. So we wanted to make sure that we reach the positive outcome and that the change will happen” (Managers’ group f). Nurses thought that hospital leadership was responsible for allocating enough resources for mentoring. The training process progressed best in the units in which the mentor nurses were given the most work time. “It has been the most essential factor for succeeding that each of the nurses had time on four days to do infant observations with the mentor in the beginning” (Managers’ group a). If the mentor nurses had to continue their clinical patient work alongside mentoring, the training was slowed down. “We didn’t get enough time to do the bedside pair practices even if we told that to a head nurse” (Nurses’ group e).
Some of the mentor nurses felt that they carried the responsibility for the success of the training, which was stressful. “It was really hard. I was so tired at some point. We took care of so many things that I think were not even our responsibility” (Nurses’ group e). In addition to support from the leadership, the mentor nurses pointed out that the competency of the trainer mentors and master trainers and their supportive approach were important to them. The trainers could provide peer support and advice on how to best facilitate the implementation. “The trainer mentors supported us even when we didn’t get support from managers” (Nurses’ group e).
Context/unit design
Participants stated that unit design complicated the implementation because patients’ rooms were not optimal regarding parents’ presence. “Parents attend much more but our rooms are not suitable for that. It causes conflicts because we don’t have rooms” (Nurses’ group b).
Recipients/multidisciplinary commitment
Nurses reported that the implementation was difficult if the doctors were not committed to the training program. Nurses stated that in that case, they were powerless to help the parents’ voices to be heard. “Our physicians were not engaged in the program and it made our work difficult” (Nurses’ group g). The nurses believed that the hierarchy between doctors and nurses could impede mentor nurses from mentoring the doctors, and they suggested that doctors might have been more involved if they had other doctors as their mentors. Participants perceived that the multidisciplinary commitment of staff was important for the success of the implementation. “The fact is that our staff is behind this. They had to stretch and make this possible” (Managers’ group f). Commitment was expressed as shared views on the desired change and the determination to succeed in the implementation. “I think the only way to implement this is that everyone works together for a common goal and knows what we are talking about” (Managers’ group b).
The elements affecting the implementation of the Close Collaboration with Parents Training Program were similar, even if the units differed from each other regarding architecture and size. The shift in care culture toward more FCC happened in each unit, but the depth and scope of the new attitudes and practice varied among the units.