Rebalancing of professional identity roles in an integrated maternity and neonatal care setting designed to increase parent autonomy: a qualitative study among health professionals

ABSTRACT

This case-based qualitative study explored the professional identity as experienced by health professionals working in an integrated maternal-neonatal ward when their practice changed from a “paternalistic” model, in which physicians and nurses were in charge, to a shared or “consumerist” model, to increase parent autonomy. We analyzed transcripts of focus group discussions and interviews with 60 health professionals on their experiences with empowering parents and described factors associated with themes of professional identity. The changes most affecting professional identity were the constant proximity of parents to their newborns and the single-family room design. These changes influenced three themes of professional identity: (1) connectedness and relationships (2) communication, and (3) competencies. A fourth theme, values, beliefs, and ethics, affected how the health professionals coped with the changes in the first three themes. When empowering parents of newborns in a hospital setting, health professionals experience beneficial as well as threatening shifts in their professional identities. Values, beliefs, and ethics associated with family integrated care helped health professionals to embrace their new roles, but other values, beliefs and ethics could create barriers. Continuous professional identity development in a patient-inclusive team is a topic for future research.

KEYWORDS:

• Family integrated care
• integrated neonatal and maternity care
• interprofessional care
• parent empowerment
• professional identity
• qualitative research

Introduction

A well-developed professional identity leads to satisfaction with the professional role and is essential for the wellbeing and growth of the professional and for the quality of care (Fitzgerald, 2020). Professional identity comprises “all the attributes that define a person according to their career or profession, including cognitive, behavioral, and social constructions” (Willetts & Clarke, 2014). A concept analysis by Fitzgerald (2020), drawn from literature on health-related fields, identified five groups of attributes of professional identity: (1) Action and behaviors: the stronger the identification with behaviors and activities, the greater the professional identity and, usually, the stronger the professional’s job satisfaction; (2) Knowledge and skills: People need to satisfy their curiosity, knowledge and need to be skilled; (3) Values, beliefs and ethics: Integration or internalization of personal and professional values is important for commitment to the profession; (4) Context and socialization: When identification with the work group is strong, self-identification as a professional is strengthened. People need to connect to others; (5) Group and personal identity: People need social recognition and attention.

Studies on developing a strong professional identity during vocational training advocated its critical importance for safe and effective clinical practice (Cruess et al., 2019; Rasmussen et al., 2021). While these studies on identity formation in students and trainees, Kirby et al. (2019) and Codsi et al. (2021) focused on work practice changes and their implications for already developed professional identities. Changes in work may conflict with the currently established professional identity of health professionals, as professional identity is context-dependent. This can have consequences related to job satisfaction, burnout, and service delivery (Codsi et al., 2021; Fitzgerald, 2020; Kirby et al., 2019).

Background

In healthcare, work is changing from a “paternalistic” model, in which physicians and nurses are in charge, to a shared or “consumerist” model to increase patient autonomy (Kilbride & Joffe, 2018). Implementing the family integrated care (FICare) concept in neonatal care implied a significant change in work practices, as parents become the primary caregivers of their newborns and equal members of the team (Franck et al., 2020). Staff who used to provide direct care to the newborns themselves is now expected to train, coach and support parents to become autonomous primary caregivers, who make care decisions jointly with the staff (American Academy of Pediatrics, 2012; Stelwagen et al., 2022). FICare challenges the staff to accept parents as knowledgeable experts and constant factors in the newborn’s life (Codsi et al., 2021; Franck et al., 2020). Shared decision-making aligned with parental autonomy requires attention to skills, attitudes, and contextual factors. Staff must be able to put shared decision-making into practice, explore the parents’ perspective from a holistic point of view, and apply tailored coaching. They must be able to integrate this new work approach into their predominantly protocol-based work routines (Lenzen et al., 2018). Staff members are required to make extra efforts to prevent, recognize, and resolve dysfunctional relationships and power struggles with parents (Read & Rattenbury, 2018; M. Stelwagen et al., 2021). An important pillar underpinning the model of FICare is to provide staff with the skills that enable them to educate, mentor and support parents in caring for their infant in the NICU (Waddington et al., 2021).

In a previous article, we described the transition from a traditional hospital design with separate maternity and neonatal wards to a design that integrates maternity and neonatal care to empower parents toward autonomous parenting (M. A. Stelwagen et al., 2020). The key element of this integrated infrastructure is to keep parents and their newborns together, even in highly complex care situations, by providing specialized couplet-care according to the FICare principles for mothers and newborns in single-family rooms (SFRs) with rooming-in facilities for partners.

There is a lack of understanding of the consequences of work practice changes due to implementing medical rounds with parents, equal partnerships, and parental involvement in decision-making (Vetcho et al., 2020). We aim to explore how health professionals experience changes in their professional identity due to the realization of parental autonomy through empowering parents in an integrated maternity and level-2 neonatal ward, and what they need to adapt.

Methods

Design

We used a case-based qualitative exploratory study design (Creswell & Poth, 2017) with a framework analysis approach (Gale et al., 2013; Ritchie, 2003) guided by a theoretical framework that builds on a concept analysis of “Professional Identity” (Fitzgerald, 2020). We conducted this study in two phases.

During the first phase, we aimed to explore the multidisciplinary staff’s experiences with empowering parents toward autonomous parenting in the integrated ward. We used two data collection strategies, focus group discussions (FGD) and semi-structured interviews, to facilitate both open discussions and more in-depth/anonymous interviews to increase reliability (Moon, 2019). The key question was “What experiences concerning parent empowerment do you have with the integrated infrastructure with SFRs, couplet-care, rooming-in and FICare?” To further develop the interview questions, we used the key principles of FICare (Table 1). The open discussions provided rich data on how empowering parents changed the staff’s work. Because we felt the topic was not sufficiently explored for pediatricians and neonatal nurses, we added one-on-one in-depth interviews with these health professionals in the second phase (Table 1).

Table 1. Interview guide Phase 1: Focus group discussions and interviews.

Topics FICare	Key question	Specific questions	Supplement question in case of an in-depth interview:
Respecting and acknowledging parents as primary caregivers	What experiences do you have with the integrated infrastructure of couplet-care, Rooming-in, SFRs and FICare to empower parents?	What facilitates you within the new integrated ward to empower parents?	Can you tell us more about your experiences with … … …
Respecting parents are in control		Which barriers do you experience?
Establishing an equal partnership with parents		What effects do you see in parents? How do you notice parents are “empowered”?
Sharing information and making shared decisions		What experiences do you have compared with traditional (separate) infrastructures?
Coaching and counseling parents
Communicating and coordinating the care-treatment policy with parents
Extra topics interview guide Phase 2: Interviews
Topics professional identity	Key question	Specific question
Identity	What experiences concerning changing staff roles and identities do you have within the integrated infrastructure of … .	Why did you choose your profession?
Autonomy
Relationships and cooperation with colleagues		What changes have most affected your work and why?
Changes in roles
Professional training and development

We followed the Standards for Reporting Qualitative Research (SRQR) (O’Brien et al., 2014). The study design was approved by the OLVG ethics committee (amendment WO 20.119).

Setting

We conducted this study in an integrated ward for complex maternity and level-2 neonatal care that empowers parents as primary caregivers from admission onwards, integrating the concepts of SFRs, couplet-care, rooming-in and FICare (M. A. Stelwagen et al., 2020). Both parents are encouraged to stay as often and as long as their personal situation allows. After discharge of the mother, sleeping facilities are available for one parent. Mothers are present for a mean of 20 (IQR 9–24) hours per day, and partners/fathers are present for a mean of 9 (IQR 2–15 per) hours per day (van Veenendaal et al., 2022). In our previous study, both parents regarded this infrastructure as a school for autonomous, independent parenting (M. Stelwagen et al., 2021).

This “integrated care” setting with 53 SFRs is part of a public teaching hospital in Amsterdam with approximately 3000 births annually. Each year, level-2 neonatal care is provided to approximately 400 newborns born at 32 0/7 weeks’ gestation or more, and approximately 70 newborns with a post-conceptional age of 30 weeks or more who are convalescing from intensive care.

The integrated nursing team comprises maternity, neonatal, and mother-and-newborn nurses who are trained to provide different levels of care for mothers and newborns. The (para) medical team comprises gynecologists, pediatricians, midwives, physiotherapists and speech therapists.

Participants and procedures

Health professionals were eligible to take part if they had work experience in the study setting. We recruited health professionals through a general call for voluntary participation in the department’s newsletter and via e-mail. We chose a purposeful sample from the respondents, aiming for different perspectives and a valid reflection of the multidisciplinary care team. For the first phase, we selected neonatal, maternity, and mother-and-newborn nurses, pediatricians, gynecologists, midwives and physio- or speech-therapists. For the second phase, we selected pediatricians and neonatal nurses. In both phases we selected participants (male/female) with varied education and work experience. Each participant received information about the procedure, including details about the recording of the interviews, the anonymized verbatim transcriptions, and the analysis. All participants provided written informed consent.

Data collection

In the first phase (May 2018 to January 2020), the first author (M.S.), who is an experienced moderator, and an independent moderator (W.G., A.G. or L.H.) led the FGD, that were alternated with semi-structured interviews conducted by three Master of Health Sciences students (W.G, A.G., and A.K.) supervised by M.S. In the second phase (June 2020 to April 2021), the first author and a Master of Health Sciences student (S.V) held interviews with neonatal nurses and pediatricians.

The FGD and interviews were in Dutch, and they lasted a maximum of 60 minutes. We sent interview summaries to the participants for member checking. Data were collected until the research team decided that no new relevant data emerged.

Data analysis

To analyze the transcripts of both phases, we used a framework analysis approach characterized by using both an inductive and deductive analysis (Gale et al., 2013; Ritchie, 2003) using MaxQda software as a datamanagement tool (VERBI Software, 2007). We chose to construct a framework based on a recently conducted concept analysis on professional identity by Fitzgerald (2020), drawn from health-related fields (Table 2).

Table 2. Framework for professional identity.

Themes	Definition/operationalization	Study finding themes	opportunities	challenges
1. Actions and behaviors	What professionals do, how they talk and how they perform. Shared behavior and acting like others in the group makes a person feel acknowledged as a member of a profession.	Communication	Direct/less hierarchical with parents.	Nurses feel left out/ignored in conversations by physicians and parents
			Increased shared decision making	Communicate more cautiously
			Educate parents on how to communicate effectively with physicians	Clinical reasoning during medical rounds
				More frequent and longer discussions
				Communication time to learn from each other and for supervising trainees
2. Knowledge and skills	The required expertise, body of knowledge and skills, and certification	Competenties	More moments for intense coaching and education of both parents, “80% of our job”	Coaching and educating both parents,“entire family systems,” And care for the “healthy newborn at home”
				Communication and organization skills during medical rounds with parents
				Learn and perform skills in neonatal care with the watchful eyes of the parents
				Coaching, educating and assessing of health professionals in training in single-family rooms.
3. Values, beliefs, and ethics	Norms, values, and beliefs about what good care means for parents and newborns. Shared goals and morals.	Values, beliefs, and ethics	Care is now truly focused on the needs of the parents and their child;’ “I am much closer to why I became a doctor. I am just a happier healthcare professional.”	Concerns about cost-effectiveness of care, exceeding hospital care and offering hotel services, personal norms that are at stake, parents had too much to say, and stagnation in the progress of the newborn’s care process
4. context and socialization	Professional identity cannot be separated from social identity. If identification with the group is strong, self-identification as a professional is strong. Professionals achieve status, social recognition, and access to the community of practice. They share social responsibilities and obey traditional norms and values in the context of political, cultural, and historical realities.	Connectedness and relationships	Increased presence and contact with the parents. Newborn care: more of a shared responsibility	physical contact with the newborns decreased, fewer “hands on” time with the children The loss of performing as a medical expert team, more distance in the cooperation between nurses and doctors, parents see less of the expertise in the single-family rooms.
			Develop closer relationships with parents and play a more valuable role for the parents	Loss of a liaison position of nurses between parents and physicians
			More direct access to good colleagues with extra areas of expertise	Time for nurses to collaborate and have contact with colleagues. Loss of performing care side-by-side in the open bay ward supporting each other.
				Alignment of medical professional interests, through interdisciplinary training and socialization
5. Group and personal identity	Being recognized by society. Self-identification, how one identifies with others and separates oneself from others

Based on a concept analysis of professional identity in health related fields (Fitzgerald, 2020).

We first conducted the inductive analysis, applying the following steps: (1) Familiarization: two researchers reviewed the transcripts. (2) Identification: both researchers independently coded text fragments and clustered the codes into categories. The transcripts of the first round were analyzed with a focus on work changes due to the empowerment of parents. The transcripts of the second phase were analyzed with a focus on changes in professional identity. Second, the deductive phase comprised the following steps: (3) Indexing: researchers independently assigned the codes and categories to a framework of professional identity with a priori themes (Table 2). (4) Similarities and differences in coding, categorization and assigning to the themes were discussed until consensus was reached. (5) Mapping and interpretation: the researchers discussed relationships and clarified and explained connections between and within themes and categories, working toward and developing explanations for the findings of research objectives. (6) Determination of the themes. Steps 1 through 4 were performed by the first author in collaboration and alternation with one of the 4 master students and a colleague of the teaching department (S.O). Steps 5 and 6 were performed during regular meetings of the entire research group.

Findings

Participants’ characteristics

We included 60 health professionals (58 females) from different disciplines. For each discipline, the health professionals’ average period of professional experience was over 10 years, ranging from 3 months to 30 years. Their mean age was 37 years, with a range of 26 to 63 years.

In the first phase, we included 45 health professionals: 22 specialized nurses, 13 pediatricians/residents, 4 gynecologists/residents, 3 midwives, 2 physiotherapists and one speech therapist. Ten pediatricians, 4 gynecologists and 3 midwives participated in the 3 FGD. The other health professionals participated in the 28 interviews. In the second phase, we held 15 in-depth interviews with 10 pediatricians/residents and 5 neonatal nurses.

Experiences of changes in work affecting professional identity

The framework analysis resulted in 3 themes in which work changes affected professional identity: (1) connectedness and relationships, (2) communication, and (3) competencies. A fourth theme, values, beliefs, and ethics, emerged as having a direct impact on how the health professionals coped with the first 3 themes of the framework of professional identity (Table 2). Because we did not focus on the social identity of the health professionals outside the organization, no codes were associated with the fifth theme of the framework.

Health professionals mentioned two major factors that were perceived to influence work changes. The first factor was the constant proximity of parents to their newborn in the SFRs. Especially health professionals primarily trained in neonatology perceived this as a significant contrast to the traditional ward, where parents were usually present once or twice a day, often during nursing rounds. The second major factor was the SFR itself. For all disciplines, it was a new experience to provide care for mother-newborn couplets, in the presence of a partner, in a SFR, compared to the former open-bay neonatology ward and the maternity ward with rooms for 2 to 4 mothers.

Connectedness and relationships

A major change health professionals mentioned was the increased presence and contact with the parents, which focused their attention on aligning the care of the newborn in full partnership with the parents: “The responsibility [of caring for the newborn] has become more of a shared responsibility” (Neonatal Nurse [NN]1). Health professionals said they could develop closer relationships with the parents. Some health professionals reported they could play a more valuable role for the parents because they could observe the parents more and better. They could ask parents sensitive questions in the privacy of the SFR, for instance, about their emotions. This change toward closer and more personal contact with parents was even more pronounced by physicians: “I like it… parents see me every day. This means that I can also have very special moments with parents because I can also ask about the parents” emotions in a SFR … I have much more personal contact with them … more in-depth contact … build more of a bond’ (Pediatrician [P]1). Nurses indicated that this sometimes made them feel left out or redundant, and experienced loss of contact with the physicians, because previously, nurses were the liaison between parents and physicians.

Health professionals said that the time for physical contact with the newborns had decreased, as parents became the primary caregivers. Some neonatal nurses experienced this as a loss, because comforting newborns was an important part of their work and they had chosen their profession to care for newborns. Some missed these moments of closeness with the newborns. A physician also lamented this shift: “In the previous ward we had more contact with the newborns because the parents were around less often … We now have fewer ‘hands on’ time with the children … that is too bad… our role now is to empathise with the parents” (P9).

Nurses experienced decreased time to work together and have contact with their colleagues. In the former situation, nurses said they cared more side-by-side in the open-bay ward supporting each other.

Another disadvantage of the SFRs that nurses mentioned was that parents might value them less because they see less of their professional expertise. ’I think in a SFR parents see less of the expertise we have … in the open-bay ward, parents constantly saw how we acted in acute and complex situations‘ (NN2).

Some nurses perceived the integration of the three nursing teams more positively than they expected. They mentioned that they gained more direct access to good colleagues with extra areas of expertise. ’The thing we were most reluctant to do, integrate two teams [neonatology and maternity] … Of course we all experienced bumps, but everyone said: we fortunately gained good colleagues‘ (NN 1).

A neonatal nurse said: ’Now [in the SFRs] I experience more distance in the cooperation with the doctors than when we worked together on an open-bay ward… Sometimes I actually feel a need to act like a team with the doctors. For example, when we perform the medical rounds in the SFR we do not discuss before we enter the room… We step into the rooms and ask the parents: how do you think your baby is doing? It is less of a team with a feeling: we are going to do this together“ (NN2). In contrast, a more recently trained nurse mentioned: ”Parents are getting much more involved, but I do not see that as a replacement for my role as a nurse‘ (NN5).

Pediatricians expressed the need for better alignment of medical professional interests, through interdisciplinary training and socialization. ’I think we should train and socialize more … I think it just creates more patience with each other’ (P5).

Communication

Health professionals mentioned they communicated more directly and less hierarchically with the parents in the new setting. Nurses described this communication as “a unique way of conversing with parents … now we speak to parents on an equal level” (NN1). Physicians regarded the parents more as a serious interlocutor, with an increased recognition of the parents’ expertise. “They [parents] have more knowledge now … they are the first to notice if something is wrong … we have to … fine-tune even better with the parents” (P1). As the lines of communication between physicians and parents were perceived as more direct and less mediated by the nurses, some nurses mentioned they felt “left out” in conversations or felt ignored by physicians and parents. Some nurses were still searching for their role in the communication between doctors and parents, while others already took on the role of coach for the parents. One nurse explained: “Sometimes nurses are present [during medical rounds] ‘just along for the ride’ … sometimes they feel useless …, they say; let the doctor talk to the parents, and afterwards I will hear what they decide … They just do not feel that they are being heard” (NN1). A more recently trained nurse explained that she educated parents on how to prepare for the medical rounds and how to communicate effectively with physicians. ‘I often discuss with parents, before the medical rounds, “it is going well, what steps you think your newborn can take today?” (NN5).

Health professionals said they have to communicate more cautiously. “It is sometimes difficult to ask the right questions … To sense the situation [psychological state of the parents] and respond to it … that is why I feel I have to be very careful” (NN2). Neonatal nurses mentioned that parents show their feelings, emotions and frustrations more in the SFR. “Parents, especially if they are present day and night, are exhausted … they can tolerate less” (NN2). In addition, a nurse said “Mothers show they are vulnerable …, it’s always been like that, but we didn’t see it then … the contact in this setting with parents is much more intense than in the former [open-bay] ward” (NN4). Physicians also reported communicating more cautiously when making shared decisions with parents. “Sometimes I have to be more careful with my words… if there are issues I am not sure about, or parents should not be concerned about yet … then I will try to be subtle in how I speak … it then feels like I am hiding something, which is not the case” (P1). Another physician mentioned finding it more difficult to train students in clinical reasoning during medical rounds with the parents present. “If I want to conduct a medical round with a training element for students, that does not help the parents at all if they are present … it only leads to … confusion” (Gynecologist [G] 3).

Especially physicians felt they had more frequent and longer discussions with parents and needed to convince them more. “Sometimes I cannot get through to parents … the communication takes too long… then I argue with parents… whereas in the open-bay ward, we used to start antibiotics and afterwards we would call the parents to inform them” (P1). A nurse said that parents sometimes rely more on their own expertise and “less and less” on the expertise of professionals. She explained that this results from the fact that parents now know their child better, but also they look for information about medical treatments on the Internet and form their own opinion about the best for their newborn. Some health professionals, both nurses and physicians, felt that those parents were questioning their professional expertise.

Due to the SFRs, nurses experienced a loss of communication time with their colleagues to learn from each other and for supervising and training their fellow students. ’When we were in the open-bay room with three colleagues, we heard what others said to parents or saw what they did. Now… I have much less insight into it“ (NN1). ”I find supervising students very difficult … we discuss everything beforehand …and I only often observe little fragments’ (NN3).

Competencies

Health professionals mentioned that they need training to become competent for the new way of working. “Parents need education, training and support, but so do health professionals” (P7). A competency that health professionals do not consider new, but that is becoming different and more intense, is coaching and educating parents. “Parent counseling … it was 50% … now it is 80% [of our job]” (NN1). “I am talking and coaching more now, rather than doing everything myself” (NN3).

Health professionals mentioned new learning objectives to train parents in family care, as they could observe entire family systems and feel more directly involved because both parents were present more often. “I am not just observing the newborn, but I am observing everyone in the SFR” (NN3). For example, health professionals said they now encourage partners more in supporting the mother in caring for their newborns, even at night. “When they [fathers] sleep all night and the mother is up all night comforting their newborn… most of my colleagues get the fathers off their beds… try to encourage them [to take on their role and support the mother]” (Mother & Newborn Nurse 4).

Physicians mentioned imbalances in their role and a lack in their communication and organizations skills during medical rounds with the parents. ’Suddenly, we have parents taking part in medical rounds, even when we do not know yet what needs to be done or what will be discussed, that is very difficult’ (P7). ’We must have the capability to discuss [medical policy] in the room [with the parents]. So, I think health professionals should master this skill’ (P6).

Residents mentioned that the presence of parents makes it more difficult for them to learn and perform skills in neonatal care because of the watchful eyes of the parents. “I’m still learning and need to refine my technique … . It is sometimes stressful when parents are watching” (P3). These residents felt they should show self-confidence and not show any weaknesses in their skills, and that they should perform well right away: “I think that, more than in other hospitals, it is necessary that we know very well what we are doing … When the parents are present, we prefer to say and do things right. Parents also notice when we have doubts” (P2).

Values, beliefs and ethics

Values, beliefs, and ethics were important factors in how health professionals experienced the changes in relationships, communication, and competencies. Health professionals said that they were “pleased to see that care is now truly focused on the needs of the parents and their child” (NN3) and “how familiar parents are with their child” (P7). They were pleased to reach goals in line with values such as “parents and newborns belong together” (NN5), and “educating and coaching the parents leads to better neonatal care” (P6). “With this way of working I am much closer to why I became a doctor. I am just a happier healthcare professional” (P3).

What made it more difficult for the health professionals to adapt to the changes were situations in which values, beliefs and ethics of others differed from their personal ones. Sometimes, health professionals questioned the cost-effectiveness of care. “I do not have time to go on and on [talking] … about a decision that is straightforward for us” (P1). Health professionals also reported concerns about an undesirable shift from professional medical care to hotel services. Nurses, for example, mentioned that they did not want to make up the fathers’ beds nor clean the rooms. “Our ward looks like a hotel. People get different expectations” (NN1). Some health professionals expressed concerns that their personal norms were at stake. ‘When he [the father] is standing next to me in his boxer-shorts … it sometimes oversteps my boundaries‘ (NN2). Some health professionals said that they thought parents had too much say. “Sometimes … parents have a very important role in … the care plan, but it can be ‘over the top’ … I still struggle with that” (NN4). Some nurses felt that parental participation sometimes led to stagnation in the progress of the newborn’s care process. “Sometimes the parents themselves are not ready for the next step … The result is that the infant stays in an incubator three days longer than necessary” (NN3). In contrast, according to the health professionals, other parents overestimate the physical condition of their newborn.

Discussion

We found that the constant presence of parents in the SFRs was perceived to result in changes in the health professionals’ connectedness and relationships with parents, newborns, and colleagues. As intended in the FICare concept, the responsibility for the newborn’s care is shifted back from the health professionals to the parents; parents take up their roles as primary caregivers and act as equal members of the interprofessional team. Consequently, health professionals adopt new roles that fit with FICare, but they sometimes experience a need to rebalance in order to resolve perceived side effects of these new roles, such as feeling more undervalued, less noticed by parents, and more isolated from colleagues. Health professionals reported a need for advanced competencies concerning communication, organization, and family care. Values, beliefs, and ethics played an important role in how health professionals coped with the changes.

Our study shows that especially for nurses, the more isolated work context of SFRs can interfere with important enhancing factors for professional identity that are mentioned in the literature, such as feeling a valued member in a team and being recognized as an expert (Rasmussen et al., 2021; Spinnewijn et al., 2020). The finding that nurses feel more isolated from colleagues in SFRs is in line with the literature (Coats et al., 2018; Doede & Trinkoff, 2020; Winner-Stoltz et al., 2018). Also, our finding that nurses feel less noticed and valued by parents in SFRs is consistent with the findings of studies in neonatal open-bay wards, where mothers valued nurses working together as a team (Jones et al., 2016), and where parental trust scores were higher than in SFRs (Tandberg et al., 2018).

Health professionals in the present study felt they had to be very careful in communicating with the parents. This finding is in line with the finding of Reid et al. (2019) that poor communication with parents in NICUs can be a barrier to implementing of family-centered care. Spinnewijn et al. (2020) found that physicians’ daily clinical perspective is based on what literature claims is best for patients, rather than considering what patients actually want. They concluded that modern medical education should pay attention to the culture change from health-professional-centered care to patient-centered care. Benzies (2016) advocated for ongoing education of health professionals in relational communication as an essential part of FICare. Perhaps it would be helpful to have a clear relational framework to show the dynamic process from “parents who need to be cared for” to “autonomous parents as colleagues,” as Codsi et al. (2021) suggest.

In our findings, we saw that specifically nurses’ professional identities might be affected by their experiences of being left out in the communication between parents and physicians, and by feelings of being redundant, as parents take up their roles as primary caregivers. For decades, nurses have constantly been present at the newborns’ beside and acted as liaisons between doctors and parents explaining medical procedures, between doctors and newborns monitoring the newborn’s condition, and between parents and newborns promoting health (Coats et al., 2018; Senyuva et al., 2020). Ensuring good parent-professional relationships within interprofessional teams requires that each professional involved competently engages in relational work and interprofessional collaboration (Gram et al., 2023). The education system has not kept up with training in team-based care that includes patients as team members. In a systematic review of interprofessional education programs in neonatal care, Parmekar et al. (2022) found only one study (out of 17) involving parents as learners. We believe it is important to study whether and to what extent modern education prepares health professionals and parents through joint education for shared decision-making, effective communication, conflict management skills, feelings of trust and equality, and the establishment of everyone’s role.

Our study shows differences between health professionals who easily took on their role as coach and others who found this transition difficult. According to Lenzen et al. (2018), a role change from health expert to coach in shared decision-making is complex. It requires extensive training to achieve skills in the holistic exploration of parents’ perspectives, goal setting, and action planning. A joint education program like “the interprofessional leadership development programme” might contribute to this. Parents reported that the program had increased the ability to see other points of view, skills in communicating across professions, skills in conflict management, and feelings of trust and equality with health care providers (Margolis et al., 2017).

Our study showed that several values, beliefs, and ethics were helpful for embracing parental autonomy in neonatal care, while other values, beliefs and ethics may provoke resistance. Examples of beliefs that may create resistance are the idea that work became more time-consuming while nursing staff are scarce, and a sense of shift from hospital care toward hotel services, which is consistent with the findings of Coats et al. (2018). The literature highlights that knowledge and skills are not enough to create a professional identity. After achieving confidence in one’s own abilities, professionals must internalize the core values and beliefs of the profession (Fitzgerald, 2020). Toivonen et al. (2019) emphasized that health professionals must be properly trained for the changes, by helping them to reflect on the specific values, beliefs, and ethics of FICare. Continuous professional training to empower staff is an essential factor for developing professional identity (Rasmussen et al., 2021). The question arises, whether health professionals are properly trained to include patients, or in this case parents, in their “inter-professional” teams. Seminars aimed at better understanding of physician-patient relationships, the so-called “Balint” groups, may be beneficial to guide health professionals to become more patient-centered (Yazdankhahfard et al., 2019). Future research may reveal the best approach for continuous professional development.

Limitations

All health professionals in our study had similar cultural backgrounds. Since identity is subject to culture and context (Fitzgerald, 2020), the findings might have been different if the study had been conducted in a different culture and context (Helmich et al., 2017). In some countries, family-centered or integrated care has not yet been ideally implemented (Heidari & Mardani-Hamooleh, 2020) and they have to deal with a lack of facilities for parental participation. However, several of the reported issues affecting the identity of health professionals in pursuing greater parental autonomy seem to some extent generalizable. Further research in other countries and cultures will help to identify generalizable professional identity issues that need to be addressed during implementing patient empowerment.

Conclusion

In a setting in which parents of hospitalized newborns are empowered to become independent, the role of health professionals evolved as parents took on the role of primary caregivers and became the constant presence at the newborns’ bedside. For health professionals, this change resulted in shifts in connectedness, communication, and competencies. Some health professionals took on their new role easily, but others experienced uncertainties, as they felt excluded from communication, less valued, or even redundant. In their new role, they had to combine coaching parents toward autonomy and caring for them. Health professionals expressed a need for specific communication skills. Values, beliefs, and ethics related to FICare helped health professionals embrace their new roles, but other experiences could act as barriers.

We recommend making all professionals aware that pursuing autonomy for parents as primary caregivers may generate shifts in the team members’ professional identities. It is essential to address the foreseeable shifts in connectedness, in communication with parents, and in the competencies needed for each discipline’s new role, for instance by offering an education and support program. Reflection on values, beliefs and ethics related to FICare is needed to embrace patient empowerment fully. Continuing professional development is essential to adapt professional identity to changes in the workplace.

Authors contributions

CRediT author statement Conceptualization: Mireille A. Stelwagen, Alvin H. Westmaas, Anne A.M.W. van Kempen, Fedde Scheele. Data curation: Mireille A. Stelwagen, Anne A.M.W. van Kempen. Formal analysis: Mireille A. Stelwagen, Alvin H. Westmaas, Anne A.M.W. van Kempen, Fedde Scheele. Investigation: Mireille A. Stelwagen, Alvin H. Westmaas, Anne A.M.W. van Kempen, Fedde Scheele. Methodology: Mireille A. Stelwagen, Alvin H. Westmaas, Fedde Scheele. Project administration: Mireille A. Stelwagen. Software: Mireille A. Stelwagen. Supervision: Alvin H. Westmaas, Anne A.M.W. van Kempen, Fedde Scheele. Validation: Mireille A. Stelwagen, Alvin H. Westmaas, Anne A.M.W. van Kempen, Fedde Scheele. Visualization: Mireille A. Stelwagen. Writing -original draft: Mireille A. Stelwagen. Writing-reviewing & editing: Mireille A. Stelwagen, Alvin H. Westmaas, Anne A.M.W. van Kempen, Fedde Scheele.

Research team

The research team consisted of members with different types of expertise: nursing science (MS, AW), qualitative research (MS, AW, FS), Competency-Based Education (AW, FS), obstetrics (FS), neonatology (AvK) and FICare (AvK, MS).

Acknowledgments

The authors would like to thank all the participants who discussed their experiences. We furthermore are grateful to Annabel de Groot, Willemijn van Ginneken, Angelique van Kippersluis and Sarah Verdonk for data collection and analysis assistance, Lotte Hoeijmakers for data collection assistance, Saskia Oosterbaan for analysis assistance and Lisette van Hulst for editorial assistance.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Mireille Stelwagen

Mireille Stelwagen, RN, MSN, PhD is a nurse educator and a researcher in the Department of Teaching and in the Department of Pediatrics at OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands.

Alvin Westmaas

Alvin Westmaas, MSc, PhD, is an associate professor in the Department of Social Psychology, Maastricht University, Maastricht, the Netherlands and a lecturer at the Faculty of Health, University of Applied Sciences Leiden, Zernikedreef 11, 2333 CK, Leiden, The Netherlands.

Anne Van Kempen

Anne Van Kempen, MD, PhD, is a neonatologist in the Department of Pediatrics at OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands. Twitter handle @kempenanne.

Fedde Scheele

Fedde Scheele, MD, PhD, is a professor in health systems innovation and education at the VU University Amsterdam and Amsterdam University Medical Center, a gynecologist in the Department of Gynecology and Dean of the Department Teaching at OLVG Hospital, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands. Twitter handle @Feddescheele.