Designs for the Most Vulnerable of Patients

Neonatal intensive care units (NICUs) provide a setting for the care of some of the most vulnerable and fragile of patient populations: newborn infants. Some of these infants were born too soon or too small, whereas others may have had a difficult birth process or transition into life. The parents and families of these little ones are also vulnerable and fragile as they try to make sense of how their anticipated joy turned into a stark new reality. They often enter a scene unlike any other.They see little Plexiglas boxes or other strange pieces of equipment containing babies-some no bigger than your hand, others normal-sized-with tubes inserted in their noses, mouths, and many different parts of the body. The hum and whir of equipment and alarms overwhelm their senses and add to their anxiety. They are filled with fear-sometimes for the health of the mother, and always for the infant-and other emotions, part joy, part loss and grief. But fear-of the unknown present and future-governs. They are also full of questions, trying to make sense of it all: "Will my baby live through this experience? Will the baby be 'normal'? What did I/we do to make this happen? I feel helpless; what can I do to help? "NICUs can be frightful places, but they are also sacred places filled with the hopes and dreams of families and the healing hearts, hands, and minds of providers. NICUs are sacred places because they are where the transition to life occurs for most infants who enter, and sadly a transition to death for others. During these transitions, babies are nurtured, loved, and cared for by some of the most competent and compassionate of caregivers, parents, and providers working in partnership to make the transition as easy as possible. This issue of HERD features articles on NICU design and its effect on the patient/family and provider experience. As in other areas of healthcare design, evidence about the design of NICUs is emerging, but the goal is to create a healing environment for both families and providers to work together to facilitate the growth, development, and healing of fragile neonates.Transitions in CareThe immediate care environment for the neonate is the radiant warmer, isolette, or small crib, but the larger context of care is either an open ward, a cluster of several infant beds in one space, or a single-family-room (SFR) design. Previously, the open-ward design was considered state-of-the-art design for NICUs because it was the most costefficient model with less square footage required per bed, and it allowed for maximum observation of the infant, the sharing of nursing resources, and parent-to-parent interaction. Open-ward design continues to be the predominant design of NICUs across the United States and in other countries.In the last decade, more evidence and opinion have emerged about the challenges of caring for growing premature infants (preemies) and sick infants in an open ward. Some have been concerned about patient safety issues in the openward design, including noise and light levels that could be detrimental to neurological and brain development in the growing preemie (Chen et al., 2009; Krueger, Schue, & Parker, 2007; Shepley, 2004; White, 2004, 2011) and the potential for the transmission of infection from one infant to others in an open-ward design (Mesman, 2009; Walsh, McCullough, & White, 2006). Lack of privacy for the family to interact skin to skin with an infant (placing the infant on the mother's or father's bare chest) or for the mother to breastfeed the infant has also been a challenge in the open ward.Some nurses perceive that it is easier to observe multiple infants in an open-ward design because they often care for more than one infant at a time. Other providers have commented that parent-to-parent interaction is helpful and facilitated by open wards (Domanico, Davis, Coleman, & Davis, 2010). Still, some healthcare decision makers voice concerns that the SFR NICU is more costly than the open-ward design because of the increased square footage associated with the SFR design and increased operational costs related to greater staffing needs, although no published evidence validates these concerns. …