Understanding parenting occupations in neonatal intensive care: application of the Person-Environment-Occupation Model.
Abstract: The adoption of family-centred care principles within neonatal intensive care, including support for the development of the parental role, has been increasing in profile over the past decade. During this period, occupational therapy has also had an emerging role in the provision of services within neonatal intensive care. However, there has been limited exploration of the concept of parenting as an occupation as a means of supporting parental role development within the neonatal intensive care unit (NICU). In accordance with the philosophy of family-centred care, opportunities exist to determine how the occupational efforts of parents and preterm infants can best be supported.

This paper provides a review of the current literature and its application to the Person-Environment-Occupation (PEO) Model as a framework for illuminating the acquisition of parenting occupations in the NICU. Illustration is provided of how the application of the PEO Model can be used to direct occupational therapy practice to incorporate a focus on family-centred care and the development of an occupation-based approach through which practice can be enhanced, ensuring that both the infant's and the family's needs are recognised and addressed.

Key words:

Neonatology, parenting, occupation.
Article Type: Report
Subject: Occupational therapists (Practice)
Infants (Premature) (Care and treatment)
Neonatal intensive care (Methods)
Neonatal intensive care (Models)
Authors: Gibbs, Deanna
Boshoff, Kobie
Lane, Alison
Pub Date: 02/01/2010
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: Feb, 2010 Source Volume: 73 Source Issue: 2
Topic: Event Code: 200 Management dynamics
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 219519339
Full Text: Introduction

Increasing survival rates for infants born preterm and recognition of the importance of parent-infant attachment in this vulnerable client group has resulted in a growing profile of the benefits of adopting family-centred care principles in the neonatal intensive care unit (NICU). However, a range of barriers continues to have an impact on the uptake of family-centred care in this highly complex setting. The aim of this literature review was to consider this ongoing issue from an occupational performance perspective, through a description of the application of the Person-Environment-Occupation (PEO) Model (Law et al 1996) to support the provision of family-centred care in the NICU. A significant amount of neonatal intensive care research and practice literature is focused on the viability and survival of the premature infant and on decreasing the potential for neurodevelopmental sequelae. This paper considers the issues surrounding the admission of an infant to an NICU from a new occupation-based context and seeks to promote improved understanding of parental involvement in neonatal intensive care through the consideration of parenting occupations.

Background context

Occupational therapy services in NICU

Occupational therapy has had an emerging role in service provision to premature infants and their families for over 10 years (American Occupational Therapy Association [AOTA] 1993, Gorga 1994, Vergara et al 2006). However, the specific role attributes of occupational therapists working within NICUs often differ between facilities and also differ between countries. These geographical and facility-based inconsistencies in service delivery make this an area of practice within which the occupational therapy role and unique contributions are difficult to articulate to other professions in this highly complex setting.

Over the past decade, occupational therapy services within NICUs in the United States and parts of the United Kingdom have become increasingly established, with clearly defined roles and competencies forming part of the professional literature (Vergara et al 2006). The specific occupational therapy role attributes within NICUs vary, but service provision may include:

* Guidance on positioning of infants to support neurobehavioural regulation (for example, habituation to external stimuli, motor responses and consolidation of and transition between sleep/wake states) and prevent postural sequelae. Supportive positioning helps to promote infants' self-regulation of their autonomic and motor systems and reduces the risk of muscle imbalance leading to, for example, shoulder retraction and hip external rotation.

* Assessment and guidance regarding the infant's neurobehavioural state--this includes key working with parents in understanding their infant's neurobehavioural cues and preparing parents for interaction with their infant

* Early identification and implementation of supportive practice and/or intervention for infants identified as at risk of significant neurodevelopmental sequelae (for example, intraventricular haemorrhage and periventricular leukomalacia, which may lead to motor, sensory and cognitive dysfunction)

* Assessment and support of feeding development (within North America)

* Follow-up assessment and/or intervention for infants born below 1000 grams birth weight, before 29 weeks' gestation or the presence of other risk factors for neurodevelopmental sequelae.

The type and frequency of services provided is often dependent on the multidisciplinary team structure within individual NICUs and on historical role delineation for individual professions within the team.

During this period, there has also been ongoing discussion in the literature regarding the skills and competencies required by therapists working in this area (AOTA 1993, Hyde and Jonkey 1994, Dewire et al 1996, Hunter 1996, Gorga et al 2000, Vergara et al 2006), resulting in the publication of position papers detailing the knowledge and skills requirements for occupational therapists in neonatal intensive care (Vergara et al 2006). For occupational therapists providing services in an NICU, this suggests the need to establish a balance between acquiring detailed knowledge and skills regarding specific assessment and intervention practices, gaining an understanding of neonatal health issues and their required management, and consideration of the underlying occupational issues for these infants and their families. This period has also seen an increasing focus on understanding the implications for parents of preterm infants during the intensive care admission (Lawhon 2002, Browne 2003, Gavey 2007, Howland 2007, Thomas 2008), which has served to give more prominence to the consideration of parental role and support requirements. Therefore, in addition to knowledge of application and theory regarding infant neurodevelopment, there is also an opportunity to consider occupational performance as a means of identifying how both parents' and infants' occupational efforts can be supported.

To date, there has been limited exploration of the concept of parenting as an occupation as a means of supporting parental role development within the NICU. Although the birth of a preterm infant that requires admission to an NICU represents a major crisis for parents that may influence the acquisition of their parental role and engagement in parenting occupations, only one study from within the field of occupational therapy has specifically investigated parental stress within the NICU and the potential influence on parent and infant characteristics (Dudek-Shriber 2004). With the study results indicating that the most stressful aspect of having an infant in an NICU is related to altered parental role and relationship with their infant, recommendations were made for an ongoing focus of the occupational therapy profession in facilitating a positive parent-infant relationship and providing intervention that focuses on supporting the parents' occupational role (Dudek-Shriber 2004). Although this research highlights the contribution that supporting parental occupational role performance may have in reducing stress, and facilitating engagement in their infant's care, there is still limited understanding and research on how the concept of occupation may be used to explore and understand parental experiences in the NICU and what implications this may have for occupational therapy practice in this setting.

Family-centred care

In recognition of the importance of parent-infant attachment, there has been increasing advocacy for the adoption of principles of family-centred care in the NICU environment (Harrison 1993, McGrath and Conliffe-Torres 1996, Sweeney 1997, Hurst 2001, Moore et al 2003). Many neonatal units have adopted a family-centred approach to caregiving, in which promotion of the parent-infant relationship and family involvement in the infant's care are of central importance (Franck and Spencer 2003). Johnson et al (1992) have defined family-centred care as a philosophy of care, which:

* Recognises and respects the crucial role of the family in relation to the infant's care

* Supports families by building on their strengths and encouraging them to make the best choices

* Promotes normal patterns of living during a child's illness and recovery.

The philosophy of family-centred care provides a contextual base to the increasing focus within the NICU on supporting the acquisition of parental occupations.

To facilitate the implementation of family-centred care within the NICU, a number of principles have been identified (Harrison 1993, Hurst 2001). First, family-centred care promotes the encouragement of families to participate as fully as possible in caring for and making decisions about their hospitalised infants. Second, it ensures respect for the diversity of families and their values and beliefs. This aims to facilitate the development of supportive care partnerships in the NICU and beyond (Hurst 2001, Malusky 2005, Griffin 2006).

Despite the adoption of care philosophies that recommend the use of family-centred care within the NICU, however, there are still barriers that limit its uptake. Peterson et al (2004), in a survey of nurses working in NICUs and paediatric intensive care units (PICUs), identified a discrepancy between the elements of family-centred care that have been acknowledged as essential and the reality of what is executed in practice. The respondents to this survey employed in PICUs rated the importance and implementation of elements of family-centred care more highly than those working in NICUs. However, it was also acknowledged that this response is influenced by the realisation that infants are typically admitted to an NICU shortly after birth and there is a perception that there is, therefore, limited time for them to be integrated into the family structure (Peterson et al 2004). Further, the study recognised that the amount of time that NICU nurses spend with these fragile infants and the relationships that develop over prolonged lengths of hospitalisation may pose a conflict to the implementation of family-centred care (Peterson et al 2004).

Qualitative studies that have explored parental perceptions of NICU have also served to identify the inconsistencies in the adoption of family-centred care practices. Cescuti-Butler and Galvin (2003), in a grounded theory study, determined that parents felt that they had failed to integrate into the NICU during their infant's admission. They were conscious of an implied burden on staff, identifying feelings of not belonging in the unit and being especially careful of staff and staff routines (Cescuti-Butler and Galvin 2003). Sweeney (1997), in a personal reflection on an NICU and PICU experience, identified factors through which the presence or absence of a family-centred care approach had a significant impact on the family experience. Issues such as involvement in decision making, the provision of information to orient families to new environments, experiences or available supports, the necessity of a two-way information exchange, consistency of caregiving (both caregivers and care plans) and basic courtesy were experienced as either enabling or constraining, based on the attitudes and actions of the health professionals involved (Sweeney 1997).

There has been significant research on and industry acknowledgement of the barriers to the implementation of family-centred care, and subsequently the support of the acquisition of the parental role. However, it remains a multifaceted problem that needs to be addressed in order to ensure greater consistency in the implementation of family-centred care principles in the provision of neonatal care. While the barriers to family-centred care provision exist, it remains difficult for all NICU-based staff to support parents adequately in the acquisition of the role of parenting. Consideration of this issue through a means that allows the multifactorial components to be considered in relation to each other is required given the complexity of the factors, which may constrain or enable the provision of family-centred care. Occupational therapists, with their understanding of core philosophies regarding occupational performance, are in a key position to explore these multifactorial barriers and consider how parental occupational performance can be maximised within this setting.

Understanding parenting occupations: the Person-Environment-Occupation (PEO) Model

The consideration of parenting as an occupational role acquired by the parents of preterm infants within an NICU provides a context for exploring the complexities of the implementation of family-centred care in this environment. Occupation is a core domain for the occupational therapy profession. As a result, a number of theoretical paradigms and frames of reference are in use within the profession to delineate the complex processes that exist between individuals, their roles and occupations, and the environments in which they take place. The Person-Environment-Occupation (PEO) Model (Law et al 1996) was developed as a framework within which to examine person-environment processes in the context of occupational therapy practice.

The PEO Model has been used as a tool to examine complex occupational performance issues in hospital, community, academic and research settings (Strong et al 1999). Because of the significant impact that the physical and social NICU environment has had on the provision of family-centred care, the PEO Model was selected for use to explore parental occupational performance in this environment. Strong et al (1999) described the PEO Model as providing therapists with a practical, analytical tool to assist in the analysis of problems in occupational performance, to guide intervention planning and evaluation and to communicate clearly occupational therapy practice.

The PEO Model (Law et al 1996) considers human functioning and learning as a product of complex person, environment and occupation interactions. The model is conceptualised as the person and his or her environments and occupations interacting dynamically over time (Fig. 1, Law et al 1996). Law et al (1996) defined occupations as clusters of activities in which individuals engage in order to meet their intrinsic needs for self-maintenance, expression and fulfilment. Occupations are then carried out within the context of individual roles and capacities, and multiple environments (Law et al 1996). Occupational performance is the outcome of the transaction between the person, the environment and the occupation. The extent of the congruence of this transaction is represented by the degree of overlap between the three spheres of the model (Strong et al 1999).

[FIGURE 1 OMITTED]

The PEO Model can therefore provide a framework within which to consider the acquisition of parenting occupations in the NICU by understanding the person-environment congruence (Law et al 1996). There are a number of interrelated barriers identified in the literature that can influence the uptake of family-centred care within the NICU. From these it can be determined that varying factors within an NICU admission may have a constraining effect on occupational performance, resulting instead in a person-environment incongruence.

Occupational analysis of parenting occupations

From a review of the literature that has explored the uptake of family-centred care in NICU, it is apparent that the issues identified within the current body of knowledge can be attributed to either a person, environment or occupation factor.

Person

The grounding of the PEO Model in the tenets of client-centred care (Strong et al 1999) supports its applicability when considering the parents of preterm infants experiencing care in an NICU. Person in this context may relate to both the infant and the family caregivers, which can include the mother and father of the preterm infant, both individually and as a dyad, in addition to wider extended family contexts (for example, the involvement of siblings or grandparents).

In general terms, preterm infants have limited capabilities to tolerate stressful or overstimulating environments and they typically respond in a disorganised manner (McGrath and Conliffe-Torres 1996). In infancy, Whitfield (2003) described preterm infants as being generally more difficult to settle, more irritable, and having less predictable sleep patterns and poorer emotional regulation. They have difficulty in focusing attention selectively and are less likely to orient to or spend time exploring novel stimuli, habituate less efficiently to visual stimuli, and encode information less efficiently when compared with term-born infants (Whitfield 2003). Therefore, the NICU experience may be a significant factor disrupting the development of the infant's ability to self-regulate his or her autonomic, motor and state systems. For example, preterm infants may exhibit physiological disorganisation (for example, colour change, increased respiratory effort, poor temperature regulation and disturbed visceral and digestive functioning), difficulties with sustaining relaxed tone and posture, and difficulties in habituating to their environment (Brazelton and Nugent 1995). The disruption of self-regulation may result in subsequent difficulties for parents when trying to establish opportunities for engaging with their infant.

Previous studies have also indicated that an infant's admission to an NICU can be a period of intense stress for parents arising from the premature birth and medical sequelae. Hughes et al (1994), in a phenomenological study, identified common stressors for parents of preterm infants, including infant appearance, health and course of hospitalisation, separation from their infant and not feeling like a parent, and communication with staff. A qualitative study by Wereszczak et al (1997) enabled further identification that stress experienced by parents during an NICU admission is attributed to varying sources. These included environmental stressors such as the infant's appearance and behaviour, staff behaviour and communication, the sights and sounds of the environment and alteration in parental role. Situational stressors such as uncertainty, the perception of severity of their infant's illness and prenatal events also contributed to parent-identified stress within the NICU.

Dudek-Shriber (2004), in a quantitative study using a parental self-report instrument with 162 parents, confirmed that the stress experienced by parents during their infant's NICU admission may often be diffuse, with a range of factors contributing to it. However, the results also indicated that the subscale in which they reported the greatest stress was related to an altered parental role and relationship with their baby. In addition, the degree of stress experienced by parents needs to be considered. For some parents, their response in the NICU situation has been aligned with posttraumatic stress reactions (Holditch-Davis et al 2003). Contributing to experiences of parental stress are the limitations to the development of situational control, with parents wanting and needing to be given opportunities to experience a sense of ownership and control within the intensive care unit in relation to their infant rather than remaining on the periphery of his or her care (Fenwick et al 2001).

The parents of preterm infants all present with individualised experiences, which bring them to a common point of their infant's admission to an NICU. So, although guidelines for the implementation of family-centred care have been developed, they may not take into account the journey that these individuals have experienced in becoming the parent of a preterm infant and, therefore, the need for the implementation of a care model that supports their individualised needs as parents and a family.

Environment

The PEO Model considers the environment as the context within which the occupational performance of an individual takes place. Environmental contexts are not static and can have an enabling or constraining effect on occupational performance (Law et al 1996). Therefore, the addition of an unanticipated technological environment such as the NICU, in which occupational role development occurs may have a significant influence on how the occupation of parenting is acquired and performed. In this context, the environment may include not only the physical aspects of the environment, including the design of the unit, lighting and medical equipment, but also the staff with which parents may interact as a key component of that environment.

The physical environment of the NICU is a significant source of stress for preterm infants and their families. The NICU is a milieu in which infants consistently encounter overwhelming stimuli, including bright lights, loud noises, excessive handling by multiple caregivers and intrusive and uncomfortable treatment interventions (McGrath and Conliffe-Torres 1996). It involves a barrage of factors for which the preterm infant is not developmentally prepared. Factors influencing the infant's status include illness severity, noise, light, repetitive pain, exposure to analgesia, sedation and other drugs, and separation from normal maternal interaction, including touch, smell, sucking and voice (Whitfield 2003). Prematurity disrupts the normal growth and development of the brain and nervous system.

Beginning shortly after conception and continuing into childhood, the brain and nervous system experiences a period of rapid growth and maturation between 25 and 40 weeks' gestation. For preterm infants, this period of development coincides with a time when the infant is likely to be exposed to various environmental stressors that are developmentally inappropriate and potentially harmful to the infant's sensory systems (McGrath and Conliffe-Torres 1996).

Families also experience the stress of the highly technological environment. They encounter life-sustaining equipment, monitors, multiple tubes and intravenous lines, intrusions by multiple caregivers and an overwhelming fear of the unknown, which can serve to create physical and emotional barriers between a preterm infant and his or her family (McGrath and Conliffe-Torres 1996, Miles and Holditch-Davis 1997, Byers 2003). These environmental stressors can prove an immediate barrier in enabling parents to engage readily with their infants.

Supporting parental involvement and promoting family-centred care approaches can also be significantly influenced by the social environment that exists within the NICU, particularly in consideration of the relationships between parents and health care providers in the NICU. Fenwick et al (2001), in their study involving 28 mothers of preterm infants, described parent-staff interactions as either facilitative or inhibitive. Staff that provided facilitative interaction were perceived by mothers as collaborators in their infant's care, who provided enhanced opportunities for them to be with their infants in a meaningful way, such as through participation in routine caregiving and opportunities for holding their infant; however, staff who were perceived as inhibitive displayed behaviours that restricted maternal efforts to achieve a sense of physical closeness with their infants (Fenwick et al 2001). Conflict between parents and staff can result in a variety of parental behaviours as they attempt to regain some control over parenting their infant. These may include vigilance in watching over their baby, safeguarding him or her from harm, feelings of disaffection as a result of the communication with staff, a guarding of communication style and a fear of reprisals or recrimination if they speak out about their infant's care (Lasby et al 1994, Fenwick et al 2001). These studies have begun to explore and articulate communication styles that facilitate the development of parent-infant attachment. However, the strategies and recommendations aimed at increasing facilitative interaction are reported in generalist terms. The transfer of these recommendations into clear guidelines for practice is not yet evident (Beveridge et al 2001, Peterson et al 2004).

Although research to date has focused predominantly on parental perceptions of their communication with staff, a study has also been conducted which investigated health care staff's perceptions of the dyadic relationships that are formed between staff and parents in the NICU. Walker (1998), in a survey of 298 neonatal nurses, determined that 90% of respondents did not believe that any of the care practices or policies/procedures of the NICU contributed to the barriers that confronted parents in the acquisition of parenting roles and skills. This indicates that there is potential for limitations in understanding the implications of staff caregiving practices on parental role acquisition, since the aforementioned studies have indicated clearly that such an influence exists from the perspective of parents. Given that health care staff act as gatekeepers in parents' access to their infants in the NICU, the development of a positive collaborative relationship between parents and staff is important in supporting family-centred care.

Occupation

Occupation is defined as 'groups of self-directed, functional tasks and activities in which a person engages over the lifespan ... clusters of activities as tasks in which the person engages in order to meet his/her intrinsic needs for self-maintenance, expression and fulfilment' (Law et al 1996, p16). The ability to engage in a cluster of activities that are identifiable as parenting occupations in the NICU may be necessarily limited due to the infant's fragility and the nature of the highly intensive care support that he or she is receiving.

The contrast between actual and anticipated parenting experiences is an additional constraining factor to parental involvement in the care of an infant. The parents of preterm infants have lost many of the usual rituals that are associated with the birth of a new baby, such as leaving hospital with the baby and receiving congratulations on the baby's birth. Lasby et al (1994) identified that the loss of these expected maternal events make it difficult to gain acknowledgement of motherhood, which creates difficulty in the establishment of meaningful moments between parent and infant. Findlay (1997), in her discussion of the adaptation process experienced by parents of preterm infants, includes descriptions of parental experience of pregnancies ending prematurely and the commencement of a process of adjusting to unanticipated situations. Parents of preterm infants are subsequently required to develop their parenting skills in the very public domain of the NICU. This, in itself, may be problematic due to the acknowledged barriers that exist to parenting in the NICU, such as the physical environment, the mismatch between parents and their infant in terms of readiness for interaction, the inability to provide all of their infant's caregiving, and the support of staff regarding parental competence in caregiving (Gale and Franck 1998).

Miles and Holditch-Davis (1997), in their development of a conceptual framework relating to the needs of parents in an NICU, identified that the loss of the anticipated parental or caregiving role can leave parents with feelings of helplessness, struggling for opportunities in which to exert their parental role. This framework was confirmed in a subsequent study, in which 25 of 31 mothers who participated in the study reported that their loss of the anticipated role contributed to difficulties in developing positions as advocates and decision makers on behalf of their children (Holditch-Davis and Miles 2000).

Christiansen (1999) supported the facilitatory influence of occupation on the person, with the suggestion that the performance of occupations is a means of creating and maintaining identities. This, therefore, is an important component to consider in relation to parenting within an NICU. Difficulties exist for parents attempting to consolidate their self-identity, resulting from limitations in access to their infant and the restrictions that they encounter in engaging in activities that they anticipated and identified as being a parent. Christiansen (1999) introduced the concept of 'possible selves'. Possible selves are imagined views of our future identities and give meaning and structure to an individual's thoughts about the future. This is congruent with parental perceptions of their NICU experience, where they identify the loss of their anticipated parenting role (Wereszczak et al 1997); that is, activities such as feeding, bathing and dressing their infant that they identified throughout their pregnancy, which supported their imagined identity of being a parent, were not available to them. Hammell (2004) suggested that the loss of the ability to participate in occupations that are important to individuals can erase perceptions of capability and competence.

Person-environment-occupation transactions in an NICU: implications for practice

In considering the rich information currently available that delineates the person, environment and occupation aspects of the NICU experience for preterm infants and their families, the PEO Model can be used to consider how the development of occupational performance can be facilitated. By exploring the transactions that may occur between each aspect of the model, focusing on the person-occupation, occupation-environment and person-environment relationships (Strong et al 1999), it may be possible for occupational therapists to identify strategies that could serve to overcome the barriers and support optimal occupational performance when working with individual families.

Occupational therapy as a profession is concerned with assisting individuals to participate in the chosen occupations that are necessary for health, development and quality of life (Parham and Primeau 1997). In the critical care context of an NICU, this perspective can be diminished in importance owing to the primary focus on components of infant functioning and survival. Opportunities exist to determine how both the infants' and parents' occupational efforts can be enabled and supported (Holloway 1998). The areas of PEO transactions would serve as a starting point for exploring how parental occupational performance within the NICU context may be enabled.

The application of the PEO Model in relation to the context of parenting in the NICU is illustrated in Fig. 2.

[FIGURE 2 OMITTED]

Occupation-environment transactions

Within the NICU, occupation-environment transactions are clearly evident. As a result of the intensive medical support required by the infant, occupational engagement will be limited by the physical barriers of medical equipment in the unit, such as the infant being ventilated or nursed in an incubator. As outlined earlier, the social environment of the NICU may also have an impact on the fluency of occupation-environment transactions.

Person-environment transactions

Person-environment transactions can also be present. These can include the local visiting hours and regulations for the unit that may inhibit parents' participation in caregiving activities. Owing to the tertiary nature of NICUs, many infants are admitted to units that are geographically distant to their parents' home, making regular visiting difficult. Within the social environment, consideration needs to be given to the support provided by NICU staff for parents to assume a caregiving role for their infants. This includes the communication style undertaken by health care providers and whether this is perceived by parents as facilitative or inhibitive.

Person-occupation transactions

Within the person-occupation transactional area, the management of the infant's fragile medical status during caregiving can be a significant barrier to occupational engagement. When planning care, consideration also needs to be given to:

* The availability of opportunities for parents to be engaged in caregiving activities

* Parents' fear about being involved in the care of their infant and not wishing to harm their baby

* Parents' previous experience and confidence in the performance of caregiving activities, such as bathing and feeding, and how these can be best enabled.

Supporting parental occupational adaptation

Within each of the elements of person, environment and occupation, barriers exist that are difficult to remediate. For example, depending on the structure and operational functioning of an NICU, the moderation of some environment factors, such as unit design and lighting policies, may be limited. However, bedside factors, such as the management of incubator covers, alarms and voice level, are able to be moderated through collaborative staff efforts. Similarly, the types of medical and technological intervention required to support the infant are beyond the control of the occupational therapist. However, what can be considered is how best to support parents' occupational adaptation to this environment. Providing an intervention approach that includes consistent and understandable explanations regarding equipment function, clearly identifying and making available opportunities for parents to participate in safe but meaningful contact with their infants, and equipping parents to interpret their infants' state regulation in relation to timeliness of interaction can all have a positive effect on the person-environment transaction and, ultimately, the parents' occupational role development.

The development of evidence-based neonatal care approaches, such as the Newborn Individualised Developmental Care and Assessment Programme (NIDCAP) (Lawhon 2002, Als 2008), has been key in supporting multidisciplinary NICU-based staff in the provision of a highly individualised developmentally supportive care approach for preterm infants. The aim of individualised developmentally supportive care models, such as NIDCAP, is to alter the focus of neonatal care from the traditional task-oriented or procedure-oriented approach to a focus on processes and relationships, including the increased involvement of families (Westrup 2007). The NIDCAP approach is based on the premise that infants' own behaviour provides the necessary information in order to determine their current capabilities. It is a comprehensive programme, involving structured behavioural observation of the infant and the provision of individualised caregiving support of the infant's developmental goals (VandenBerg 2007). The ongoing process of NIDCAP supports continual adjustment of the environment and caregiving practices in light of the infant's and parents' developmental needs (VandenBerg 2007).

NICUs that have adopted a NIDCAP approach are more able not only to be truly responsive to the needs of infants with a resulting impact on developmental outcome but also to centralise the role of an infant's family and address the PEO transactions inherent in the NICU admission. Successful implementation of individualised developmental care requires the full commitment of NICU staff at all levels and provides a significant shift in how health services address the needs of this client group (VandenBerg 2007, Westrup 2007). However, like family-centred care, the uptake of NIDCAP and other developmental care approaches has remained inconsistent.

The PEO Model provides a structure through which an understanding of how each infant and his or her family accommodates to the NICU experience can be achieved and, more specifically, can be used to direct occupational therapy practice in focusing on family-centred care and the development of occupational performance. Therefore, although the types of occupational therapy intervention outlined at the beginning of this paper are a key element of neonatal service provision, the use of an occupation-based approach can provide a means through which practice can be enhanced by ensuring that both the infant's and the family's needs are recognised and addressed.

Conclusion

The consideration of parenting as an occupational role for the parents of preterm infants within an NICU would appear to allow the emergence of an understanding of the person-environment influences on occupational performance. By improving understanding of the parental occupations in the NICU, the provision of facilitatory or enabling service frameworks may be considered. As outlined, the PEO Model may therefore provide a new and systematic means of addressing an ongoing issue in the care of preterm infants and their families. Through the use of this approach, occupational therapists working within NICU environments have the potential both to support significantly the use of family-centred care approaches and to promote occupational adaptation with the parents of preterm infants.

Key findings

* The PEO Model provides a structure for considering parenting occupations in the NICU.

* The use of an occupation-focused approach in the NICU ensures that both the preterm infant and his or her family's needs are recognised and addressed.

What the study has added

This review provides an understanding of parental occupations in NICUs and supports occupational therapists in their promotion of family-centred care in this setting.

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Deanna Gibbs, (1) Kobie Boshoff (2) and Alison Lane (3)

(1) Barts and the London NHS Trust, London.

(2) University of South Australia, Adelaide, Australia.

(3) The Ohio State University, Columbus, Ohio, United States.

Corresponding author: Deanna Gibbs, Research Consultant--Nursing, Midwifery and AHP, Healthcare Governance, Barts and the London NHS Trust, 4th Floor, John Harrison House, Royal London Hospital, London E1 1BB.

Email: Deanna.Gibbs@bartsandthelondon.nhs.uk

Reference: Gibbs D, Boshoff K, Lane A (2010) Understanding parenting occupations in neonatal intensive care: application of the Person-Environment-Occupation Model. British Journal of Occupational Therapy, 73(2), 55-63.

DOI: 10.4276/030802210X12658062793762

Submitted: 3 December 2008.

Accepted: 15 September 2009.
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