ORIGINAL ARTICLE

ACTA PÆDIATRICA

NURTURING THE CHILD

WILEY

# Staff perceptions and challenges of the single-family room design—Experience of a greenfield level4 neonatal intensive care unit in the Middle East

Roopali Soni<fnref n="1" />,<fnref n="2" /> ID

Natalie Fairhurst<fnref n="1" />

Mohammed El Anbari<fnref n="3" />

Ana Leslie<fnref n="1" />

Charlotte Tscherning Wel-Wel<fnref n="1" />,<fnref n="4" />,<fnref n="5" />

**Correspondence**

Roopali Soni, Division of Neonatology, Sidra Medical and Research Center, Sidra Medicine, Ar-Rayyan, PO Box 26999, Doha, Qatar.

Email: roopali.soni@gmail.com

**Abstract**

**Aim:** This study was undertaken to specifically identify challenges associated with the popular single-family room (SFR) design in our new neonatal intensive care unit (NICU), so as to reap the full benefits of this architectural model.

**Methods:** A survey was sent to all 223, newly recruited staff on our NICU. Questions explored staff perceptions of family experience, safety and staff's experience of the SFR in comparison with the open bay model.

**Results:** We obtained a response rate of 66%. Most staff perceived SFR as having a positive impact on communication with families, privacy, feasibility for skin-to-skin contact, reduction in noise levels and family access to their baby. There were however concerns raised about patient safety and isolation of staff and families in the SFR architecture. Lack of opportunities to leave the patient room for breaks and increased physical demands were highlighted. Staff also felt physically and emotionally less well supported.

**Conclusion:** Whilst the SFR configuration was felt to be beneficial for infants and families, staff shared their perceived concerns regarding infant safety and isolation and staff satisfaction, and implied modifications to workflows. The survey findings resulted in re-organisation of our staff numbers and communication systems and further facilitation of parent interactions in order to optimise benefits of SFR design.

**KEYWORDS**

infant and family-centred developmental care, newborn infant, NICU design, single-family room

**Abbreviations:** SFR, single-family room; NICU, neonatal intensive care unit; IFCDC, infant- and family-centred developmental care; FINE, family and infant neurodevelopmental education.

This is an open access article under the terms of the [Creative Commons Attribution License](https://creativecommons.org/licenses/by/4.0/), which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

© 2022 The Authors. *Acta Paediatrica* published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.

<footnote n="1">¹Division of Neonatology, Sidra Medical and Research Center, Doha, Qatar</footnote>

<footnote n="2">²Division of Neonatology, Mediclinic Parkview Hospital, Dubai, UAE</footnote>

<footnote n="3">³Research Department, Sidra Medical and Research Center, Doha, Qatar</footnote>

<footnote n="4">⁴Université de Toulouse III, Toulouse, France</footnote>

<footnote n="5">⁵Centre of Physiopathology Toulouse-Purpan (CPTP), Inserm, CNRS, University of Toulouse, Toulouse, France</footnote>
# 1 | INTRODUCTION

Advances in technology and evidence-based practice have led to improved neonatal outcomes, especially at the extreme end of prematurity. These include the enhancement of the neonatal intensive care unit (NICU) environment. The traditional open ward NICU design may not fully support infant neurodevelopment and the relationship between infants and their families. Since the 1990s, there has been a trend towards single-family room units. This model offers many advantages for patient care and promotes infant- and family-centred developmental care (IFCDC).¹

A meta-analysis of the impact of single-family rooms (SFRs) on parents by Veenendaal et al.² suggests that parental presence, involvement and skin-to-skin care is facilitated, and NICU-related parental stress is reduced by the SFR model. By improving maternal presence and privacy, improvement in breastfeeding rates is reported.³ Lower depression rates in mothers and lower stress scores in both parents have been reported in the SFR model compared with open bays.⁴,⁵ SFR parents rate participation in medical rounds and emotional support higher than parents in open bays.⁶

The availability of infant-parent rooms has been associated with lower odds of composite outcome of mortality or major morbidity and a shorter length of stay.⁷,⁸ Whilst some concerns have been raised regarding the potential adverse effects of different amounts of sensory exposure in the NICU environment in an SFR,⁹ other studies have largely shown a positive long-term impact on developmental outcomes.¹⁰,¹¹

Impact on staff is controversial and has mostly been studied in situations where teams that have prior working experience together, have moved to a new NICU. Although the work environment and control of primary workspace, privacy and interruptions have felt to be improved,¹² SFRs are felt to increase the emotional¹³ and physical work of nurses along with increasing their isolation and environmental and technological obstacles.¹⁴ Surveys suggest that staff perceptions reflected concerns about the early detection of medical crises and adequate patient care in the SFR, suggesting an issue with patient safety in the SFR model.¹⁵ Studies have also alluded to other safety concerns, including communication deficits, missing equipment and supplies, suboptimal staff response times to emergency situations and staffing issues when transitioning from open bays to SFR.¹⁶ Nevertheless, in these studies, the overall benefits outweighed the challenges.

We conducted our study at the greenfield (newly established) level 4 NICU in Doha, Qatar, which was opened to admissions in January 2018, with a vision to promote infant- and family-centred developmental care. The neonatal intensive care unit was built with exclusive single-family rooms and newly recruited staff coming from various locations across the world, with variable past experiences. As the many benefits of this increasingly popular model are already well recognised, we focused specifically on identifying the associated challenges, in order to optimise the benefits to our NICU setting.

## Key Notes

* This study focused on identifying specific challenges on our neonatal intensive care unit, associated with single-family room (SFR) design.

* SFR was perceived to be beneficial for infants and families but was felt to have potential for detrimental effects on patient safety and staff satisfaction, without appropriate modifications to workflows.

* The survey findings resulted in re-organisation of our staff numbers and communication systems and facilitation of opportunities for parent interactions in order to optimise its benefits.

# 2 | NICU ARCHITECTURE, STAFF AND PATIENT POPULATION

The NICU has a total of 39 SFRs with five of those rooms suitable for accommodating ventilated twins. Each family room is furnished with a sofa-bed for parents, and many of the rooms have en suite bathrooms. In addition, there is a common kitchenette and meeting areas for parents and a spacious indoor healing garden in and around the NICU. There is a fully functional nursing workstation in each room and an additional one, shared between two adjoining rooms, immediately outside the rooms (Appendix S1).

The NICU is staffed by attending physicians (consultants), neonatal hospitalists (registrar level), advanced neonatal nurse practitioners, respiratory therapists, registered nurses and allied health professionals, with a total workforce of 223 members. Hospitalists, advanced neonatal nurses and registered nurses work on a 12-h shift system. There is no auxiliary staff for additional support to nurses and no overlapping of shifts.

As it is the primary neonatal surgical and cardiac referral centre in Doha, Qatar, up to fifty per cent of the NICU admissions are out born and referred from either other hospitals within Qatar or occasionally from surrounding countries. Patient complexity is high, with higher-than-average rates of congenital malformations due to consanguinity and low rates of pregnancy terminations. Several infants at any one time maybe on high-level cardiorespiratory support, including ECMO, or receiving postoperative care and long-term ventilation. The awareness and appreciation of family-centred and developmental care practices is still evolving in the middle east, as compared to it being routine care in most Western NICUs. Also, specifically in our NICU, the emphasis in the first few months was on the set-up, safety and quality control of the intensive care facilities.

There is a large expatriate population in Qatar (as per unit data, 66% of admissions are expatriate and only 34% are Qatari nationals). These families often struggle to commit to time on NICU due to shorter maternity leave allowance (usually 50 days), lack of a support
system and travel distance from home to hospital. They are also more anxious due to the unfamiliar environment and lack of family support.

# 3 METHODS

## 3.1 Participants

It was important to seek the experience and opinion of all professionals working in the NICU. The survey was therefore sent to all NICU nurses, physicians, advanced neonatal nurse practitioners, respiratory therapists, occupational and physiotherapists, speech and language therapists, social workers and psychologists working at the NICU in December 2018. By this time, the NICU had been open to admissions for 1 year and would give staff ample time to adjust to the new job environment and develop a valuable opinion. Participants were informed that the study sought to understand their perceptions and experience of the SFR model compared with open bay NICU.

## 3.2 Survey

The survey was created and conducted by authors CTW, RS and AL in December 2018. A Survey Monkey link was sent via email and NICU staff WhatsApp groups to all staff. In order to maximise participation, several reminders were sent over a period of a few weeks during which the survey was open. A number of nursing and doctor champions also encouraged staff participation at a personal level. The survey was anonymised and consisted of a total of 16 questions. The initial nine questions focused on demographic data about the participants. The subsequent questions explored staff perceptions of the family's experience, safety of clinical care and staff's experience of their work environment. They were asked to rate the following areas about the SFR model in comparison with open wards NICU, using a Likert scale, with 1 = bad, 3 = neutral and 5 = good. For scores <3, they were asked to provide additional explanatory comments. Opportunity for free-text comments was available (Appendix S1).

## 3.3 Data analysis

The survey data were analysed by all four authors, and statistical analysis performed by author ME.

### 3.3.1 Categorical variables

Staff demographic data, response rating and risk assessment were collected from the survey and examined using descriptive statistics (counts and frequencies). A bivariate analysis was performed to measure the potential dependence of each question of interest and

each variable from the demographic questions; this was done using a chi-squared test. All the statistical analyses and plotting were performed using the R statistical software version 4.0.4.

### 3.3.2 Qualitative assessment

The responses and comments from each participant were analysed, one question at a time. A note was made of all the responses of the Likert scale items followed by any associated comments. Those with notions pertaining to the study question were then recorded and categorised. This was done for all questions. Once all 16 questions had been considered, a concept map was created.

# 4 RESULTS

## 4.1 Demographics

One hundred and forty-eight staff members out of two hundred and twenty-three (66%) completed the survey. Whilst all participants had prior experience of working in an open ward NICU, only 9% had experience of the single-family room model. 64% of respondents were nurses, 17% medical staff and 19% allied health professionals. The majority were female, 90% were younger than 50 years of age, and 71% had more than 5 years of experience in neonatology; most respondents had prior work experience in Europe or Asia [Table 1].

## 4.2 Quantitative data

The majority of staff perceived single-family room design as having a positive impact on families' experience with regard to their privacy, feasibility for skin-to-skin contact, reduction in noise levels and family access to the infant and staff communication with families, but 64% felt that families interacted less well with each other [Table 2]. Only a few staff members felt that they were able to get physical and emotional support whilst on shift, and 55% felt that communication amongst staff was hampered. Seventy-five per cent felt that there were lack of opportunities to leave the patient room for their breaks, with 92% stating that level of physical activity was moderate to high; 85% staff felt that the risk of adverse events was increased in the SFR model as compared to open bays [Table 3]. Physical activity here refers to amount of walking done by staff during their 12-h shifts. The NICU is quite spacious with long distances to cover, even when going from one room to another.

## 4.3 Analysis of survey comments

Comments from staff were divided into three categories of effects on the family, infant and on themselves. Using common patterns and
themes within the results, a concept map was created [Figure 1]. When examining these results, it is important to consider that comments were only requested for a Likert score <3.

<table><caption>TABLE 1 Demographic characteristics of staff members</caption><thead><tr><th>Demographics</th><th>n (%)</th></tr></thead><tbody><tr><td>Age groups (years):</td><td></td></tr><tr><td>20-30</td><td>52 (35.1)</td></tr><tr><td>31-40</td><td>47 (31.8)</td></tr><tr><td>41-50</td><td>33 (22.3)</td></tr><tr><td>&gt;50</td><td>16 (10.8)</td></tr><tr><td>Staff position:</td><td></td></tr><tr><td>Medical staff</td><td>26 (17.6)</td></tr><tr><td>Nurse</td><td>95 (64.2)</td></tr><tr><td>Allied health</td><td>27 (18.2)</td></tr><tr><td>Sex:</td><td></td></tr><tr><td>Female</td><td>129 (87.2)</td></tr><tr><td>Male</td><td>19 (12.8)</td></tr><tr><td>Prior experience in a mostly SFR NICU</td><td>13 (8.8)</td></tr><tr><td>&gt;5 years of neonatology experience</td><td>106 (71.6)</td></tr><tr><td>&lt;5 years of living in Qatar</td><td>143 (96.6)</td></tr><tr><td>Country of prior Neonatal experience:</td><td></td></tr><tr><td>Africa</td><td>1 (0.7)</td></tr><tr><td>Asia</td><td>42 (28.4)</td></tr><tr><td>Australia</td><td>3 (2.0)</td></tr><tr><td>Europe</td><td>48 (32.4)</td></tr><tr><td>Middle East</td><td>35 (23.6)</td></tr><tr><td>North America</td><td>14 (9.5)</td></tr><tr><td>South Africa</td><td>4 (2.7)</td></tr><tr><td>South America</td><td>1 (0.7)</td></tr></tbody></table>

Note: Percentages rounded to nearest tenth.

### 4.3.1 | Family

Staff felt that the SFR model hampered interaction amongst different families in NICU.

* 'Families seem isolated from each other and aren't seen to meet other parents for support or even general socializing on NICU'

Comments alluded to reduced opportunities for staff to observe parent-infant interactions, parents being unable to ask for help whether a nurse was tending to a baby in another room and feeling anxious when their baby was left alone.

* 'It must be worrying for parents to find their baby alone in a room but as nursing staff have more than one patient this is a frequent occurrence and I know this has led to complaints'

### 4.3.2 | Infant

Many staff members felt dissatisfied with the quality of care they were providing whilst caring for more than one infant.

* 'Nurses are unable to care for three babies and are missing feeding cues. Infants are often left crying...the result is poor growth as these babies use more energy crying for a bottle'

* 'The single rooms mean you're constantly in between rooms running from baby to baby'

### 4.3.3 | Staff

Feelings of isolation and being unsupported were frequently expressed. The biggest concerns raised were not being able to have lunch and toilet breaks.

<table><caption>TABLE 2 Comparison of SFR model with open ward NICU. Response rating using Likert Scale from 1 to 5</caption><thead><tr><th>Parameter</th><th>Mostly<br>Good = 4,<br>5; n (%)</th><th>Neutral = 3;<br>n (%)</th><th>Mostly Bad = 1,<br>2; n (%)</th><th>p-value</th></tr></thead><tbody><tr><td>Communication with parents</td><td>74 (50)</td><td>41 (27)</td><td>34 (23)</td><td>&lt;0.05</td></tr><tr><td>Family's access to baby</td><td>100 (68)</td><td>27 (18)</td><td>21 (14)</td><td>&lt;0.05</td></tr><tr><td>Quality of patient care</td><td>51 (34)</td><td>47 (32)</td><td>50 (34)</td><td>N/S</td></tr><tr><td>Privacy for families</td><td>128 (86)</td><td>16 (11)</td><td>4 (3)</td><td>&lt;0.05</td></tr><tr><td>Families interactions with others</td><td>9 (6)</td><td>44 (30)</td><td>97 (64)</td><td>&lt;0.05</td></tr><tr><td>Feasibility of skin-to-skin</td><td>102 (69)</td><td>33 (22)</td><td>14 (9)</td><td>&lt;0.05</td></tr><tr><td>Noise levels</td><td>85 (58)</td><td>39 (26)</td><td>23 (16)</td><td>&lt;0.05</td></tr><tr><td>Communication amongst staff</td><td>25 (17)</td><td>41 (28)</td><td>82 (55)</td><td>&lt;0.05</td></tr><tr><td>Staff peer support</td><td>17 (11)</td><td>47 (32)</td><td>85 (57)</td><td>&lt;0.05</td></tr><tr><td>Ward round experience</td><td>45 (30)</td><td>61 (42)</td><td>42 (28)</td><td>N/S</td></tr><tr><td>Staff can leave room for breaks</td><td>11 (7)</td><td>27 (18)</td><td>110 (75)</td><td>&lt;0.05</td></tr></tbody></table>

Abbreviation: N/S = not significant.

Note: Percentages are rounded off.
<table><caption>TABLE 3 Risk assessment</caption><thead><tr><th>Risk assessment</th><th>Low, n<br>(%)</th><th>Moderate,<br>n (%)</th><th>High, n<br>(%)</th><th>p-value</th></tr></thead><tbody><tr><td>Level of physical activity experienced by staff in SFR</td><td>12 (8)</td><td>70 (47)</td><td>66 (45)</td><td>&lt;0.05</td></tr><tr><td>Risk of adverse events in SFR</td><td>22 (15)</td><td>53 (36)</td><td>72 (49)</td><td>&lt;0.05</td></tr></tbody></table>

<figure><img src="image_1.png" /><figcaption>FIGURE 1 Concept map of the common themes in comments from staff</figcaption></figure>

* 'It's really hard to work in single rooms. Sometimes no-one can help you if you really need help especially when doing procedures, cares or if you need to go to the toilet'

Seeking help and assistance from nursing colleagues during shift duties was felt to be challenging in the SFR model.

* 'Staff feel very isolated and it is difficult to call for help or to communicate among staff in other rooms'

* 'Nursing is always teamwork and teamwork is not possible in single-patient rooms'

5 | DISCUSSION

Our study differs from previously published studies in many ways. Most studies have been conducted on neonatal units where previously established NICU teams have moved from an open ward to the SFR setting.¹⁷ The new SFR infrastructure, along with staff of diverse experiences, with no prior working relationships, presented its challenges in the work environment. IFCDC practices, which would be routine care in many units in the West, were still in their infancy, with the initial focus being on safety of intensive care facilities for the complex patient population and organising the large team and various workflows.
Our patient population is also unique in complexity and social structure. The high rates of out-born infants, combined with a largely expatriate population and limited maternity leave, results in lack of adequate social support for families and impacts their commitment to spending time in the hospital with their infant. Also, the awareness of IFCDC practices in the local population is limited, as compared to that in the western world. The families' expectation from nursing staff in caring for their infants is often high, and nurses may also hesitate to ask parents to get involved and share the care of their infant as this would not be the expected norm.

The survey was undertaken by a significant proportion of the NICU workforce. The majority of respondents were nurses, who constitute the largest workforce in the unit. We also had good representation from doctors and allied health professionals, and hence an opportunity to obtain an opinion from more than one group of the NICU workforce. Majority had more than 5 years of experience in neonatology, but most staff had primarily worked on open wards (91%) and were naïve to the SFR model.

The SFR model was felt to have several benefits for patient families in terms of privacy, feasibility of doing skin-to-skin, staff communication with parents, access to their infant and reduced noise levels, in line with previous studies.²⁻⁸ This, however, did not translate to a perception of improved quality of patient care, perhaps due to the concerns raised regarding safety and quality of the NICU environment. The reduction in noise levels decreases the risk of overstimulation in preterm infants and is a known advantage of SRFs. However, more of positive auditory stimulus, such as parental voices, in the NICU environment is associated with better language and motor outcomes, emphasising the need for increased parental presence and involvement in the SFR setting, without which they may be potentially disadvantaged.⁹

The unintended isolation of infants, families and staff members in the SFR model seemed to be a recurrent theme of concern. As a result, staff expressed anxieties about lack of peer support, hampered team working and communication failures in the SFR model, consistent with previous studies.¹⁷ Staff felt that families interacted less with other families in the SFR model compared with open bays. Shepley et al.¹⁸ found that SFRs are associated with fewer interactions amongst different families, although the interactions that occurred in the SFR were longer in duration. Interaction amongst families is important in our NICU, given the social situation of our ex-patriate patients, where lack of family support and limited maternity leave can result in loneliness and anxiety.

Also of concern was the impact on health and well-being of staff. In line with previous studies,¹⁴ the level of physical activity in the SFR model was described by the majority to be higher in comparison with the open ward. Whilst we acknowledge that age may not necessarily be directly proportional to physical ability, as most respondents were below 50 years of age, we assume they had a good level of physical fitness. The fact that nurses were less able to take breaks on their 12-h shifts, also potentially resulted in additional staff stress and health issues.

Majority implied that the SFR NICU design may impact patient safety and suggested increasing staff numbers for safer care. Infant and staff isolation, lack of peer support, and increased physical

demands, were all perceived to be contributing to an overall risk to patient care.

Our results would imply that the routine nurse-to-patient ratios used on open bay NICUs and as recommended by BAPM¹⁹ maybe insufficient for safe working and staff well-being when applied to our SFR NICU. Different ways of working and participation in different units, and inclusion of parents in the care of the infant may of course influence these nurse-to-patient ratios. Increased peer support and better communication systems are desirable in our SFR NICU.

It is likely that the cohesion of a completely new and varied team on our greenfield NICU may have compounded the difficulties faced by staff in our SFR architecture. However, the survey was carried out after 12 months of working together and should therefore have given us reliable responses. Also, being a new quaternary NICU, the focus was primarily on quality and safety of the acute clinical services, and IFCDC practices were still immature in the first year of opening. A repeat staff survey since the implementation of interventions would be of value in reassessing staff perceptions and the impact of the changes.

Overall, whilst we realise that some of these challenges may be specific to our newly established quaternary level NICU based in the Middle East, many of the challenges identified were consistent with previous studies, as is elaborated above. The survey results raised a need for readjustment in the organisation of care on our NICU in order to optimise the benefits of the SFR model to babies and their families, mitigate any potential risks to patient and staff safety and improve staff satisfaction. A few major changes were implemented, including re-organisation of our staff numbers and communication systems and further facilitation of parental presence and collaboration with parents in the care of the hospitalised infant and also increasing the interaction amongst families [Table 4].

## 5.1 | Strengths

With the help of our team efforts, we were able to achieve a 66% response rate on the survey, which is a strength of our study.

## 5.2 | Weaknesses

As is the case with online surveys and subjective studies, the study has its limitations. We also would have benefited from a repeat staff survey to fully assess the impact of the many changes that were implemented.

# 6 | CONCLUSIONS

Our staff's opinion of the SFR model was overall good, with majority perceiving single-family room design as having a positive impact on families' experience with regards to their privacy, feasibility for skin-to-skin contact, reduction in noise levels, access to their infant and staff communication with families. The survey
<table><caption>TABLE 4 Implementation of changes</caption><thead><tr><th></th><th></th></tr></thead><tbody><tr><td>Communication</td><td>1. Telephones were supplied to each room to facilitate nurse communication with parents or other staff members at all times. This also allowed parents to call directly into their baby's room, thereby saving time and effort for parents and staff.<br>2. All nurses and doctors on shift were provided with a Vocera badge, a handsfree communication device which allows rapid and easy communication amongst staff members. These were previously only available for the doctors and lead nurses on duty.<br>3. In addition to the computers inside each room, nurses were encouraged to use the workstations and monitoring screens outside of each room, which gave them flexibility to sit outside the room when they were not required to be with the baby and allowed them to communicate and interact with their peers.</td></tr><tr><td>Workload</td><td>4. 'Floater' nurses, who were previously only occasionally available on shifts, were made a regular feature and increased to two per shift. These floater nurses are not allocated a specific workload of patients but are responsible for helping other nurses with procedures, medication administration, covering comfort and meal breaks and general care of infants. These floater nurses are skilled senior nurses who are able to assist, instruct and teach other nurses.</td></tr><tr><td>Parent support</td><td>5. A specific Neonatal Parent Support Group has now been created and regular parent events are organised in order to provide peer support to families.</td></tr><tr><td>IFCDC interventions</td><td>6. All the NICU staff (doctors, nurses, allied health professionals) have now undergone FINE level-1 training,²⁰ which is the foundation of the approach to IFCDC.<br>7. MIND (Managing Infant Neuro Developmental care) working group was created for leading and promoting neurodevelopmental care, consisting of a team of doctors, nurses and allied health professionals. It consists of six subcategories: positioning and handling, protected sleep, pain, feeding, skin-to-skin, and sensory stimulation.</td></tr></tbody></table>

was designed to specifically identify the challenges that need to be addressed in order to reap its full benefits for our NICU. We concluded that the routine nurse-to-patient ratios used on open bay NICUs may be insufficient for safe working and staff well-being when applied to our SFR model. The perception of isolation of infants, staff and families and the potential negative impact on health and well-being of staff are areas that need further focus in the SFR model. In addition, the importance of and facilitation of parental presence and the collaboration with parents in the care of the hospitalised infant needs to be further supported and emphasised in our unique population.

## AUTHOR CONTRIBUTIONS

CTW, RS and AL designed and conducted the study. Data were analysed by all authors. ME performed the statistical analysis. NF and AL created the first draft of the article and worked on the concept map of survey comments. Final draft, discussion, references and manuscript completion were done by RS and reviewed by all authors.

## CONFLICT OF INTEREST

All authors declare that they have no conflicts of interest.

## FUNDING STATEMENT

This work received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

## ORCID

Roopali Soni https://orcid.org/0000-0003-1869-1922

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**How to cite this article:** Soni R, Fairhurst N, El Anbari M, Leslie A, Tscherning Wel-Wel C. Staff perceptions and challenges of the single-family room design—Experience of a greenfield level4 neonatal intensive care unit in the Middle East. Acta Paediatr. 2022;111:2291–2298. https://doi.org/10.1111/apa.16527