My first encounter with Nathan was on my first day

He was very poorly with a poor prognosis. He had many problems which ranged from respiratory distress syndrome which meant he was a ventilated baby; a right intraventricular haemorrhage which meant he may suffer from Cerebral Palsy in the future, plus he had to have regular blood transfusions. The nursing care he received on the NICU was from an allocated nurse on a 1:1 ratio (see LOC 4 section ref ). This was due to his very complex care needs.

He had to have 1 hourly observations of his vital signs and monitor readings, in order to record evidence of deterioration or progress.As can be seen his care needs were vast, plus, he needed routine daily bloods and other daily invasive procedures. It is therefore the role of the neonatal nurse to minimise stress and discomfort felt by both infant and family (Helen and Gavey, 2002). In order to achieve this Angela, his mother, was kept informed of all Nathan's treatment and care plans. However, she had a degree of learning difficulties and Yeo (1998) explains many families with children requiring critical intervention come from lower socioeconomic groups and often lack the resources emotionally, educationally and financially to cope well.Therefore, Angela needed more encouragement and time to become involved in Nathan's care.

According to Yeo (1998), the stress of having a sick baby can blunt normal reactions, therefore information and explanations need to be simplified. This meant the information shared with Angela had to be simplified more so than usual. The goal of the nursing care Nathan received was attempting to master independent function on a par with the full term baby, (Helen and Gavey, 2002). This included the concept of tailored care to his individual needs (Helen and Gavey, 2002).However, this according to Brazelton and Nugent (1995) can prove difficult to implement, due to the high tech equitment surrounding the child.

It is therefore important to have a structure of rules and regulations in order to provide the correct care in intensive care situations (Yeo 1998). This meant that although Angela was encouraged to attend to his cares, these had to be 6 hourly and this did not always fit in with the times Angela could visit. The reason Nathan had 6 hourly cares was to prevent unnecessary touch, as this can cause him stress.Yeo (1998) explains the baby needs to have uninterrupted sleep and hygene needs only need to be carried out 6-8 hourly on poorly babies. This, however, can prove difficult for parents to understand and accept as their natral instinct is that of wanting to touch and hold their baby (Helen and Gavey, 2002). Yeo (1998) argues that careful explanations will help the parents to see this as part of their baby's treatment.

However, this often contributes to the negative aspects of caring for a child on NICU and tends to contradict the concept of family centred care (Speidel, 1978).However, although Nathan had a poor survival rate, he proved every body wrong and came out of NICU and onto Special Care. Special Care still requires an allocated nurse on a 1:1 ratio but the difference here was the care was less intense. He moved out of an incubator and into a cot and although he still required low flow oxygen, he began to develop and received age appropriate care. This meant his plan of care was being adjusted to his development and he was given bottle feeds (when the time was right) and his first bath.

Angela could now hold him more often, dress him and generally feel closer to him, in the absence of the barrier of an incubator. Helen and Gavey (2002), explain that parents tend to feel more involved in their child's care as they become more in control of the responsibilities needed to care for a baby. After several weeks Nathan no longer required special care and was placed on the transitional care section of the ward. This section is for parents to prepare and adjust for a short period of time before they take their baby home.

Parents are encouraged to stay overnight with the baby attending to all its cares in order to see how they cope. However, Angela was not ready for the responsibility of an oxygen dependant baby, due to her learning difficulties and therefore, the Multidisciplinary team decided it would be in both of their best interests if Nathan was transferred onto a paediatric ward. The ward in comparison to SCBU was a much quieter environment and far more relaxed. The care Nathan received was mostly from Angela as she had the opportunity to stay overnight with him due to a bed being in the same room as him.The nurse's role was to involve Angela as much as possible in Nathan's care, as there were no longer restrictions on when she could or could not touch or hold him.

However, according to the Audit commission, (1993) this requires the nurse to have special skills in teaching and support. Angela needed a lot of support due to her circumstances and she required being taught how to look after and cope with a baby with a long term need, which is being oxygen dependant. The care routine was now planned around Angela in preparation for her routine at home.It became Angela's decision when she wanted to bath him or take him for a walk in the pram. The idea behind this was to prepare and help her to become competent in her parenting skills and teach her how to cope with the oxygen cylinder, when out and about and in the home.

Although the ward was still a clinical area, Angela needed the support of experienced staff, Grieve (1990) explains how nurses play a vital role in enhancing the interaction between the parent and their infant, thereby indirectly promoting infant development.This is therefore in the best interests of Angela and Nathan and as Smith (1999) points out this will benefit Nathan developmentally and enable Angela to become competent in important decision making. Yeo (1998) shares this feeling and believes that without parental input the essence of developmental care will not become possible. Once Angela becomes competent with Nathan's care he will be discharged home.

However, his care does not stop there; he will be referred to the community liaison neonatal nurse, the paediatric liaison nurse, the health visitor, social worker, feeding specialist the G. P and need regular out patient appointments.The Multidisciplinary team will work closely with Angela and Nathan in order to provide continuity in seamless care. Learning Outcome 5 The underpinning aspects of Nathan and Angela's care derive from the SCBU ward philosophy (see reference ) which in turn revolves around the partnership model.

This is according to the Nottingham model, care being focused upon the infant and his family, with negotiated care being at the centre of it (Smith, 1995). The ward philosophy expresses that each baby will be viewed as an individual and care will be planned and shared with parents.This is an important aspect of Family Centred Care according to Smith, (1999) who emphasises the importance of parental involvement in decision making, communication and trust building between parents and staff. However, from my personal experience, although this concept is undertaken, there are restrictions on it. Helen and Gavey(2002) also recognise this and say that due to many monitors and equipment the idea of creating an individual plan of care can prove better in theory than in practice. Yeo (1998) agrees with this concept and believes that this leads to parents losing their role as primary carers.

However, Angela was encouraged to attend to Nathan's cares and was involved as much as possible. I did notice that whilst Nathan was in NICU Angela did not visit very often. According to Yeo (1998) this is not uncommon when parents experience fear and anxiety, however if parents are unwilling to interact with their child a delay in the child's development can occur. Therefore it is essential for the neonatal nurse to provide a psychologically nurturing environment that allows the parents to feel an element of empowerment given to them by the guidance of the nurse (Smith, 1999).

Graham (1995) believes empowering the parent may take time as they recover their confidence to become primary carers. However, in Angela's case, the nurses took notice from the ward philosophy and promoted health and education in preparation for the time that Angela could take over Nathan's care needs. I found from my time spent on SCBU that all the staff in fact adhered to the ward philosophy, however, I have noticed that the Family Centred Care is adapted, due to the specialised care required.For instance, if a mum has a planned delivary, they are shown around the ward and according to Yeo (1998)this is where Family Centered Care begins. The 'parents to be' are given written as well as verbal information in an attempt to relieve stress and anxiety. However, Yeo (1998) believes a neonatal nurse should visit a mum in pre term labour, in order to create a link with the unit where the baby will be staying.

This was not the case with Angela, a phone call from the Central Delivery Suite (CDS) had confirmed that there would be pre term baby being delivered, giving his gestational age.There was not a visit to CDS from a neonatal nurse in order to make contact with Angela and relieve some of the anxiety she may well have been experiencing. This tends to contradict the 2nd bullet point of the ward philosophy. To summarise it says care will be shared and planned with the parents. Nathan had come from CDS without Angela and because it was a preterm delivary there had been no preparation of what she was likely to expect when she did visit him. This may have caused Angela unnecessary stress and anxiety from not knowing where her baby had been taken to.

This therefore would suggest she had not been consulted about the care Nathan was to receive. This would have also meant that there had been no negotiation or planning between Angela and the neo natal staff, at this stage. Yeo, (1998) points out that pregnant women may benefit from seeing the neonatal unit as part of their antenatal induction. This would therefore give them a preconception of how and what such a unit works and looks like. It may appear that there is a breech in the ward philosophy.

Although Family Centered Care is adapted to this specialised care on a planned admission, I am not sure that the parents are always told that they will not be able to hold their baby to begin with. I make comment on this due to a recent admission. A 33 week gestational baby was admitted onto NICU and the father of the baby could not understand why handling the baby was restricted. The nurse looking after them had briefly explained that the baby needed undisturbed rest, however, the father continued to disturb the infant until the infant vomited. The Dad took offense to the nurse and her advise and has since become hostile towards the staff.

Maybe, if bullet point number 2 of the ward philosophy had been viewed in broader terms and such issues discussed with the parents prior to admission (if possible) or as soon as possible after, this hostility may have been avoided. However, Helen and Gavey (2002) argue that the pre term infant is actually deprived of the stimulation of human contact but Speidal(1975) agrees with the concept that excessive handling by nurses and parents causes adverse effects. I tend to see both sides of the argument which is parents wanting to bond with their child and the adverse effects that this may cause the child.Family Centered Care is promoted to the best of its ability in this specialised area and there is a huge difference from the way Family Centered Care is implemented on the wards I have worked on.

Parents have the opportunity to stay with their child in hospital, where as on SCBU (that I am on) there are limitations as there are only 2 bedrooms. These are usually occupied by parents who are preparing to take their babies home. I feel for Family Centered Care to improve in this unit there should be more facilities for parents to stay if they choose to during the critical period of their child's stay.