In the following sections, we discuss each of the three SOC constructs contextualised by available literature.
Antonovsky considered that in order to cope with life challenges, we need to understand what the stressors are [16
]; thereby emphasizing the need for ordered, consistent, structured and clear information. Difficulties or threats to comprehensibility occur when information is inconsistent, unclear or misleading. Antonovsky refers to these occasions as the ‘noise’ [15
] of incomprehensible and unpredictable stimuli, which can destabilise our cognitive interpretations.
Communication is one of FCCs key tenets such as parents being provided with verbal and written information provided at key points (e.g. antenatally, postnatally and discharge) and engagement in decision-making regarding their infant’s progress [17
]. On-going communication and information are identified as key features of caregiving requirements [18
] and considered important in terms of: reducing parental stress and anxiety; increasing parental self-confidence and sense of control; improving relationships between parents and their infants and facilitating active participation in staff-parent discussions [19
]. However, studies have identified how a number of parents do not receive sufficient or appropriate information, e.g. Redshaw & Hamilton [22
]. In line with Antonovsky’s theories, the ‘noise’ of poor and fragmented information is believed to inhibit open and mutual negotiations and create insecurity, frustration and isolation between parents and professionals
Wereszczak, Miles, et al. [24
] revealed how parents of infants cared for in a NICU could recall incidents of receiving incomprehensible information and their questions not being answered for up to three years post-discharge. Furthermore, whilst communication with parents has been identified as a key component in negotiating roles for the care of their infant, studies show that parents may not know what is expected of them [25
From a professional work-based perspective, Antonovsky considered the need for ‘consistency’; the extent to which our work situation enables us to understand our position within it and what the expectations are of our involvement [16
]. Research in this area has identified that a FCC vision becomes comprehensible only when “it is incorporated into the culture and daily practices of the NICU” [3
], p.450. One of the most crucial aspects of a change in culture towards a FCC ethos is how staff position themselves in relation to the parents, and their expectations of parental involvement [4
]. Changes in staff attitudes and behaviours in considering parents as primary caregivers entails a shift of power and role negotiation, which needs active advocacy [3
]. Discrepancies between knowledge and practice have also been indicated; with less experienced [27
] and better educated [28
] staff identified as having a greater awareness, appreciation and application of FCC principles.
Manageability relates to the extent to which one has the resources “at one’s disposal” to meet the demands of the stressor [16
], p.17. Antonovsky proposed the concept of “generalised resistance resources” (GRRs) described as: “any characteristic of the person, group, or environment that can facilitate effective tension management” [15
], p.99. Manageability specifically concerns the GRRs (physiological, psychological, contextual and socio-cultural) that are directly under a person’s control or by resources controlled by legitimate others, such as personal networks and professionals. Furthermore, Antonovsky considered that GRRs are dependent on the social class, culture and socio-historical contexts of people’s lives. These GRRs are considered to create prototypical patterns that are crucial to our ability to manage tension, and which subsequently determine our position on the SOC continuum.
According to Antonovsky, experiences of appropriate load balance (underload – overload) are decisive in determining the sense of manageability. Too much pressure, or the feeling that you do not have the resources (e.g. knowledge, skills, materials and equipment) to adequately address the stressor can lead to negative coping (overload); however if a person is not involved in shaping outcomes because his/her resources (or ‘potential’) are ignored or negated (underload), this may also lead to dysfunctional responses [16
]. One of the key elements, emphasized by Antonovsky, in relation to a balance between underload and overload, is active participation in decision-making. The literature suggests that the imbalance between overload and underload and negation of parental involvement in decision-making may be a key barrier to FCC implementation.
Underload is repeatedly reported in relation to parental involvement in the NICU in terms of parents’ feelings of being reduced to visitors, not involved in their infant’s care or experiencing a lack of support [29
]. Studies report how parents use different strategies to cope with underload and reduce the risk of confrontation or being judged by staff by relinquishing care to staff, mimicking staff in order to conform, or alienating themselves from their infant [30
]. For socio-economically disadvantaged parents this might be even more pronounced. For example, Flacking et al. [25
] identified how mothers from low socio-economic backgrounds were more likely to cope with negative interactions with staff through withdrawal or submissiveness.
Overload is illuminated in research that highlights how some parents have to stay with their infants not out of choice, but because of a lack of or less knowledgeable staff [32
]. Although parental presence during difficult procedures has been identified as important in building parental confidence [33
], parents also express concerns about being involved in procedures that hurt or distress their infant [34
]. Furthermore, when parents feel as if they do not have the skills to provide effective care and support or that staff “do it better”, or because of feeling overwhelmed by the task requirements, this can lead to feelings of stress, neglect and being over-burdened [20
]. Whilst involving parents as co-partners in care can improve parental confidence and self-esteem [35
], Antonovsky argued that when others decide everything for us, set the tasks and formulate the outcomes, we become “reduced to being objects” [16
From a SOC perspective, high manageability is strongly contingent on high comprehensibility. Therefore, in order to determine whether we have the necessary resources to meet the demands of the stressor, we need to understand what the demands are [16
]. A staff survey undertaken by Petersen et al. [27
] identified how a lack of organisational guidance and recognition of professional contribution and confidence for autonomous skills debilitated FCC implementation. Other research has indicated how inadequate staffing, multiple caregivers, busy units and limited time may impact upon staff’s capacity to communicate and share information with parents [32
]. Shields and colleagues in Australia [37
], Sweden [38
] and UK [39
] also found incongruence between levels of support needs between staff and parents, with staff considering that parents required more support than they did.
Other issues that impact upon manageability of FCC concern the unit layout and organisation, space, comfort and privacy. Whilst almost all NICUs in the UK have rooms in which parents can stay, many have inadequate facilities [22
]. Open rooms are common in many NICUs to accommodate technical equipment and facilitate surveillance; however these environments can be stressful for parents [40
]; with a lack of suitable facilities contributing to parents’ feelings of unimportance [25
], thereby creating ‘underload’. Parental satisfaction with care in a single-family room NICU is higher than in the traditional open-bay NICU [41
]. Furthermore, the provision of suitable facilities to enable a parent to stay overnight or even to sit comfortably and in close contact with their babies can enhance breastfeeding success [42
]; reduce length of hospital stays [43
] and rehospitalisation rates [44
]; facilitate bonding and promote access to clinical staff [14
] and reduce parental and infant stress levels [45
]. Communal areas to obtain peer support and alleviate loneliness through the sharing of experiences are also identified as beneficial [25
]. These insights indicate how suitable environmental conditions can enhance FCC provision [41
]; which in turn will have a positive impact on parents’ comprehensibility and manageability.
From a SOC perspective, formal social and contextual structures need to be in place such as appropriate involvement, access, environment and equipment in order for an underload and overload balance to be maintained [16
]. Whilst progress has been made in NICUs to enable parents unlimited visiting hours, there are still issues in terms of units closing during shift changes, new admissions, and parents asked to leave during medical procedures or ward rounds [46
]. In addition, studies have identified that whilst an environment that supports the presence and involvement of parents increases FCC, such as through a 24 hour visiting policy [47
], staff concerns about parents visiting at their convenience and interrupted work flow need to be addressed [3
Meaningfulness relates to the extent to which life makes sense emotionally. This construct concerns our perception that the demands are worthy of investment and that action is desirable [16
]. Whilst Antonovsky perceived that all three SOC components were essential in determining a person’s SOC, meaningfulness was the most important; even if a life-challenge is understandable, and we have resources to meet the challenge, if the challenge is not considered to be worthy of investment, a lower SOC would result.
In relation to a neonatal context, meaningfulness relates to the parent’s motivation and desire to develop relationships with their infants and competence within the parenting role. From a staff perspective, this construct relates to staff engagement with FCC to ensure that parenting goals and needs are attained. In addition, it relates to how meaningful FCC provision is to staff, in terms of ensuring the health and wellbeing of infants and parents.
FCC has developed from attachment theories which emphasize and value the importance of early and continued contact between parents and their infant for bonding, and the development of positive attachment relationships. Research has reported that mothers who spend more time in close contact with their infant are more likely to have higher levels of self-esteem and greater responsiveness to their infant’s signals and behaviours [48
]. However, a large body of research has identified psychological difficulties faced by parents when their infant is hospitalised. The enforced separation from their infant, the unexpected alteration of the parental role and the concerns for their infant’s wellbeing have been reported to create high levels of guilt, shame, stress and helplessness [25
]. Prolonged separation between parents and infants is believed to enhance parental difficulties in caring for their infant with implications for the parent-infant attachment relationship [49
]. Depression, social support, stress, anxiety, self-esteem, maternal well-being and perceptions of motherhood have been found to impact upon mother-infant relationships and interactive behaviours, especially with mothers of preterm infants [50
Meaningfulness can be directly associated with the relational aspects of care; with parent-staff relationships directly impacting on the parent-infant relationships. Research has identified how mothers of infants admitted to the NICU require assurance-type support [18
] and emotional based care [53
]. Sensitive and collaborative staff-parent relationships based on trust and respect can reduce parents’ feelings of helplessness and powerlessness [25
]. Moreover, they can encourage and facilitate contact between parents and their infants and can help to develop parental competence [56
]. Families who report positive relationships with staff and consider the care to be more family-centred are more satisfied with their overall care [59
]. Furthermore, from a staff perspective, research by Fegran and Helseth [56
] identified how a closer relationship between parents and staff led to clinical staff feeling more committed to take care of the vulnerable infants. This research thereby supports Antonovsky’s belief that participation in socially valued decision-making is the source of meaningfulness in one’s work [16
]. Studies suggests that almost half of all interactions studied in NICUs could be defined as “instrumental” communication (e.g. action- or task-orientated) or not considered as facilitative for parents to build nurturing relationships with their infants [60
], p.61. Staff-parent communication therefore needs to be reciprocal and embedded in the creation of trustful bonds [25
Research has identified how the highly medicalised NICU environment and clinicians’ focus on technology, rather than active collaboration and engagement with parents, has been found to impact upon the development of parent-infant relationships [35
]. When professionals set the boundaries for parental participation and parents feel that the infant belongs more to the hospital than to themselves, this can lead to feelings of exclusion, confusion and anxiety [29
]. FCC as a philosophy was developed to be an antithesis to the paternalistic approach of health-care; however ‘gate-keeping’ practices are still evident within practice [21
]. Fenwick, Barclay et al.’s [61
] grounded theory study identified how women gained access to their infants through the staff, and the ways in which nurses’ exerted authority and expertise to control these relationships. Therefore, parents’ attempts to obtain a more active role may lead to inter-personal conflict between parents and staff. Parents who do not conform to pre-defined perceptions of ‘good’ parents may be labeled as ‘difficult’, leading to communication difficulties between parents and staff and to staff restricting parents’ involvement in the care of their infants [29
]. Paliadelis, Cruickshank, et al. [62
] identified how nurses expressed difficulties in implementing FCC due to their perceptions of legal responsibilities in providing clinic care and conceptions of parental abilities. Furthermore, a number of studies have highlighted that when staff perceive parents to be competitors in the care of the infant, they may express a sense of being scrutinized, feeling intimidated by parents and fear of losing power and control [29
]. Indeed, the centrality of meaningfulness to the SOC concept is that even if we are able to understand the stressor and have the resources at our disposal to deal with the situation; if we do not sufficiently care or are motivated towards the outcomes, the situation becomes incomprehensible and we lose command of our resources [16
A further point to emphasize is how relationships with parents may lead to negative implications for staff. For example, Fegran and Helseth [56
] explored parents’ and nurses’ experiences of the parent-nurse relationship with six mothers, six fathers and six nurses in NICUs in Norway. Their findings emphasized the tension that clinicians may face in balancing between a professional and personal approach. Close relationships could create situations in which staff felt they were over-stepping the professional boundaries, and therefore attempted to restrict their level of contact with the families [56
]. This study as well as the studies undertaken by Berg and Wigert [48
] revealed that staff often found the interaction with parents more demanding than the provision of clinically based care. Professionals expressed difficulties in engaging with worried parents and instilling trust and hope [48
], with implications for compassion fatigue [64
]. A lack of emotional support for staff has been identified as one of the main barriers for FCC implementation [27
]. This research thereby illuminates how the meaningfulness of relationships with parents can be negated and minimised in practice.