Documentation in the neonatal unit: the support given to parents and their participation in their baby's care.

Aims The aim of this study was to explore how often the participation of parents in their infants' care and professionals' support for parents was documented in the clinical records and to determine how such participation and support were documented. Background Comprehensive documentation can facilitate collaboration between parents and healthcare professionals, supporting family-centred care, yet little is known about how this is reflected in practice. Design A prospective, mixed methods approach was used to analyse the clinical records of newborns. Methods The study was carried out in a large tertiary Neonatal Unit in the United Kingdom, from 2013 - 2014. We analysed the clinical records of 24 critically ill newborns using content analysis and thematic analysis, enabling us to determine the frequency of documented support and participation and how support and participation were documented. Results We identified four categories of support in the clinical records: "emotional", "spiritual", "social" and "practical support". We also identified instances where parents were encouraged to participate in their infant's care. Frequency differences in the documentation of support between infants facing a redirection of care decision and infants receiving active treatment were found. Two organisational themes were identified: "task focused documentation" and "minimal documentation of parental role". These were grouped together under the global theme "professional accountability". The perspectives and experiences of parents were minimally documented throughout. Conclusion Documentation of support towards parents and parents' participation in their infants' care was limited in terms of frequency and content. Encouraging regular, detailed documentation of these aspects of care may facilitate family-centred care.