DOI: 10.1097/JPN.
0000000000000265
J Perinat Neonat Nurs r Volume 31 Number 4, 332–340 r Copyright 
Impact of Parent-Targeted eHealth on
Parent and Infant Health Outcomes
A Scoping Review
Sheren Anwar Siani, BSc, BScN; Justine Dol, MSc; Marsha Campbell-Yeo, PhD, NNP-BC, RN
ABSTRACT
Improved communication, education, and parental in-
volvement in infant care have been demonstrated to en-
hance parental well-being and neonatal health outcomes.
eHealth has the potential to increase parental presence in
the neonatal intensive care unit (NICU). There has been
no synthesized review on the direct impact of eHealth use
on parental and neonatal health outcomes. The aim of this
scoping review is to explore eHealth utilization by families
of high-risk newborn infants in the NICU and/or postdis-
charge on health outcomes. PubMed, CINAHL, and EM-
BASE were searched from 1980 to October 2015 using key
terms for “neonatal,” “parents,” “eHealth,” and “patient
Author Affiliation: School of Nursing, Dalhousie University, Halifax,
Nova Scotia, Canada (Ms Anwar Siani and Dr Campbell-Yeo); and
Centre for Pediatric Pain Research (Ms Dol and Dr Campbell-Yeo) and
Department of Pediatrics (Dr Campbell-Yeo), IWK Health Centre,
Halifax, Nova Scotia, Canada.
Authors’ Contribution: This scoping review was developed as an eval-
uative component for a self-directed learning course undertaken by the
primary author—an opportunity provided by Dalhousie University School
of Nursing. S.A.S. was involved in all aspects of the review, from con-
ception, design, conduct of the search, and data extraction. She was the
lead reviewer of articles and wrote the initial draft of the manuscript.
M.C-Y. was involved with and oversaw all aspects of the project in-
cluding conception, design, data review and analysis, and manuscript
preparation. J.D. was involved with secondary review of the articles,
and editing and review of the final manuscript.
The authors thank the head librarian of the Dalhousie Kellogg Health
Sciences Library, Ann Barrett, for her assistance in searching for articles
in the databases. Special thanks go to the IWK Health Centre Neonatal
Intensive Care Unit (NICU) for allowing the primary author to gain insights
into the NICU environment.
Disclosure: The authors have disclosed that they have no significant
relationships with, or financial interest in, any commercial companies
pertaining to this article.
Corresponding Author: Marsha Campbell-Yeo, PhD, NNP-BC, RN,
School of Nursing, Dalhousie University, and IWK Health Centre,
5850/5980 University Ave, PO Box 9700, Halifax, NS B3K 6R8 Canada
(Marsha.Campbell-Yeo@dal.ca).
Submitted for publication: August 10, 2016; accepted for publication:
March 5, 2017.
332 www.jpnnjournal.com
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C 2017 Wolters Kluwer Health, Inc. All rights reserved.
education.” Criteria of peer-reviewed empirical studies pub-
lished in English, targeting parents of NICU infants regard-
less of diagnosis, and eHealth utilization during NICU stay
or postdischarge yielded 2218 studies. Extracted data were
synthesized using thematic content analysis. Ten studies
met inclusion, and 5 themes emerged: usability and feasi-
bility, parental perceived benefits, infant’s hospital length
of stay, knowledge uptake, and predictors of variations in
use. eHealth utilization was found to be desired by parents
and promotes positive change in parental experience in the
NICU. Actual and perceived benefits of eHealth for parents
included ease of use, higher confidence in infant care, satis-
faction, and knowledge uptake.
Key Words: eHealth, health outcome, literature review,
neonatal, NICU, parent, patient education
aving an infant admitted to the neonatal inten-
H
sive care unit (NICU) can be a stressful time
for both the infant and the parents. Many in-
fants may require lifesaving treatments such as mechan-
ical ventilation to assist them in breathing because their
lungs are immature and underdeveloped. The devel-
opmental trajectory of preterm infants requiring hos-
pitalization in the NICU is further compromised by
prolonged periods of maternal separation, which is as-
sociated with less mature motor development,1 poorer
ability to regulate stress,1,2 higher reactivity,3 and higher
mortality.4 With little experience and the unexpected
encounter with critical care medicine, families may ex-
perience feelings of disappointment, anger, anxiety,
guilt, or a sense of loss of control in their lives.5–7 In
addition, factors including distance, responsibilities to
other family members or work, and financial constraints
may further limit parental presence in the NICU.5,8
From a family-centered care lens, it is important to
integrate the family in caring for infants to enhance
neonatal health outcomes.9,10 As such, individualizing
October/December 2017
the specific health needs of the infant and the family
is imperative. This includes involving families in deci-
sions about treatment and care, which is particularly
important in neonatal settings.10–12 The top 6 primary
needs identified for parents in the NICU by Cleveland13
include (a) accurate information and involvement in
the infant’s care and decision making; (b) seeing the
infant; (c) physical contact with the infant; (d) posi-
tive perception with the NICU staff; (e) individualized
care; and (f) positive interaction and support from the
NICU staff. In addition, parents benefit from emotional
support, having a supportive NICU environment, and
having the opportunity for education in new skills with
guided training. Furthermore, when access and commu-
nication surrounding the infant’s diagnosis and care are
prioritized, this can help reduce anxiety, build trusting
relationships, and empower parents.8 Previous studies
have highlighted the importance of parental involve-
ment during hospitalization and adequate preparation
before discharge, leading to positive health outcomes
such as confidence to resume parental roles at home.9,14
Recommended standards for NICUs include providing
space for family support, particularly access to the Inter-
net and educational material in a general area or even
at the bedside to ensure parents can learn about care
for their infant and obtain parent-to-parent support.15
However, limited health resources can present a
challenge to meet the diverse and individualized needs
of infants and their families. To meet their workload
time demands, healthcare providers often find it chal-
lenging to communicate and educate parents in a way
where information is both consistent and meaningful,
particularly in the stressful NICU environment.16 Fur-
thermore, parents face the challenge of often feeling
as though they are passive observers in the NICU, re-
sulting in a lack of empowerment once they leave the
hospital.17 With the advancement of technology, par-
ents undoubtedly will seek educational health informa-
tion and support from easily accessible resources such
as the Internet. Between 70% and 80% of adults have
searched online for health information, with most par-
ents searching for parenting advice, health information,
and social support.18 However, the information avail-
able online is not always reliable.
THE NEED FOR eHEALTH
There is a growing pressure to increase the use of
eHealth tools in neonatal intensive care. Technology
is becoming more advanced, related to Web cameras
and interactive learning platforms, and many hospi-
tals and NICUs are interested in implementing eHealth
technology to enhance and expand their family-
centered care. eHealth is defined as the integration of
The Journal of Perinatal & Neonatal Nursing
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
information and communications technology (ICT) and
electronic processes to facilitate improved communica-
tion, delivery of health services, and management of
health systems.19 Often used interchangeably, mobile
health (mHealth) is a smaller subset of overall eHealth
that includes the use of various mobile technology and
functions such as use of mobile phones, World Wide
Web access, and software application support.20 For the
purposes of this article, the broader scope of eHealth
as opposed to mHealth is used, as it provides a means
to deliver an individualized health support while main-
taining the cost, quality, and portability of healthcare
services.20–22 Previous studies have shown an increase
in use of ICT by parents, including searching for med-
ical literature, networking via online support groups,
and communicating with healthcare providers using e-
mail.23–25 Furthermore, an important element in the use
of eHealth is for healthcare consumers to adopt health
behaviors and involve them in self-management of dis-
ease, therefore driving the behavior change and health
outcomes in parents and infants.20
Because of its vast benefits and usability, eHealth
has been widely used in different settings. Various uti-
lization of eHealth includes supporting parents in early
discharge after childbirth using videoconferencing, pro-
viding consultations to pediatric patients admitted to a
remote intensive care unit, and facilitating home
pediatric palliative care.26,27 In some neonatal settings,
eHealth has been widely used by the larger referral
hospital to facilitate neonatal resuscitation in remote
areas.8 Some healthcare institutions have recently
adopted eHealth technology, such as the Angel Eye
Program in Arkansas, to facilitate parental presence in
NICU using a Web camera above the baby’s bed, which
is connected to a home computer or smartphone. In
addition, by allowing parents to be virtually present at
the baby’s bedside, this feature allows for siblings or
other family members to bond with the hospitalized
infant.28,29 Moreover, parents are able to communicate
with healthcare providers and participate in virtual
rounds from a distance while maintaining visual
contact, thus further building trusting relationships with
the healthcare team. This opportunity helps alleviate
parent’s anxiety and other factors such as distance from
the hospital and commitments to work or other family
members.8,30 Despite the diverse proposed benefits
and need for eHealth, there remains a paucity of data
describing its use and benefits in supporting parental
presence in the NICU and improved health outcomes
of parents or infants in the NICU. To date, there has
been no synthesized review of the literature to help
guide healthcare providers or families of infants in the
NICU on the role of eHealth.
www.jpnnjournal.com 333
OBJECTIVE
The aim of this study was to systematically evaluate pre-
vious work to better understand whether the incorpora-
tion of eHealth to support families of high-risk newborn
infants receiving intensive care in the NICU and/or post-
discharge affects health outcomes of infants and their
families. The research questions that we planned to
address were as follows:
1. What is the acceptance of eHealth by parents of
NICU infants?
2. What are the actual or perceived health outcome
benefits to NICU infants and parents?
3. Does eHealth influence parental participation in
infant care in the NICU?
4. Does difference in parental or neonatal factors
influence the utilization of eHealth?
5. Does timing of eHealth utilization (during hos-
pital stay vs postdischarge) influence health
outcomes?
METHODS
Search strategy
Scoping reviews are most commonly used for “map-
ping,” where the review aims to summarize key con-
cepts and explore the range and extent of evidence of
a broad research area that is complex or has not been
widely reviewed.31,32 This necessitates the inquirer to be
flexible and reflexive in each stage of review process,
including refining research questions and identifying all
relevant literature regardless of study design. Using ra-
tionales as identified in Arksey and O’Malley,31 a scop-
ing review on parent-targeted eHealth in neonatal care
is most appropriate, as there has been a paucity of pre-
vious research examining the extent, range, and nature
of research activity, with significant need to identify
research gaps in the existing literature in order to sum-
marize and disseminate research findings. The stages of
conducting a scoping review are as follows: identifying
the research question; identifying relevant studies; study
selection; charting the data; and collating, summarizing,
and reporting the results.31
We searched the following databases from 1980 to
October 2015: PubMed, Cumulative Index to Nursing
and Allied Health Literature (CINAHL) and EMBASE.
The search strategy included combinations of terms
for “neonatal,” “eHealth,” “patient education,” and “par-
ents” and was developed in consultation with a librarian
specializing in systematic searches (see Table 1). Medi-
cal Subject Headings (MeSH) terms and other key word
terms were included where possible; text terms were
searched in the aforementioned databases for entries
including these terms in the title or abstract. Additional
hand searching of previous relevant research was also
conducted.

Table 1. The search strategy for this scoping review

Concept MeSH headings
Neonatal “pediatrics”; “infant, newborn”; “neonatal
nursing”; “neonatology”; “intensive care,
neonatal”
eHealth “telemedicine”; “telemedicine/methods”;
“internet”; “medical informatics”; “cell
phones”; “mobile applications”; “biomedical
technology”
Patient education “health education/methods”; “patient
education as topic”; “information
dissemination”; “delivery of health
care/trends”; “information seeking behavior”;
“delivery of health care/methods”; delivery of
health care/organization and administration”;
“health communication”; “diffusion of
innovation”
Parents “parents”; “caregivers”; “infant welfare”;
“family”; “infant care”; “parent-child
relations”; “patient satisfaction”;
“professional-patient relations”
Key words
“NICU”; “infant*”; “newborn*”; “baby”;
“babies”; “perinat*”; “neonate*”;
“paediatric”; “prematur*”; “preterm*”
“social media”; “medical apps”; “eHealth”;
“mHealth”; “mobile health”; “Internet”;
“information technology”; “communication
technology”; “Web cam”; “webcam”;
“Web-camera”; “Web camera”;
“teleneonatology”; “FaceTime”; “Skype”;
“smartphone”; “videoconference*”;
“iPhone”; “iPad”; “handheld”; “text
messaging”; “Website*”
“dissemination”; “health education”; “patient
education”; “communication”; “information
seeking”; “health promotion”
“parent*”; “mother*”; “father*”; “caregiver*”;
“care giver*”; “famil*”

334 www.jpnnjournal.com October/December 2017

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Eligibility criteria
Given the dearth of the data, we decided to include all
peer-reviewed empirical (experimental and nonexper-
imental) studies published in English, including both
quantitative and qualitative studies. Eligible studies
were required to include an intervention that targeted
parents of infants admitted to the NICU regardless
of diagnosis (eg, prematurity, surgical), various ges-
tational ages (preterm, full term), socioeconomic
status, or education level. The use of eHealth was
required to be delivered during infant’s hospital stay
at the NICU and/or postdischarge and included the
following:
1. Use of ICT such as videoconferencing app(s) and
Web-based education.
2. Extent of intervention should be tailored to the
specific health needs and health-seeking behav-
iors of parents of NICU infants (eg, educational
Figure 1. PRISMA flow diagram of the process of identifi-
information on patent ductus arteriosus).
cation and screening of articles for inclusion in the scoping
3. Quality of intervention should be directed by reli- review.
able healthcare experts (ie, healthcare profession-
als). Parents accessing unverified Internet-based
resources would not be considered as a targeted
eHealth intervention.

Study selection and data extraction RESULTS

Study selection and data extraction were completed fol-
lowing accepted standards for the completion of scop-
ing review.31,32 Eligible studies were independently se-
lected by 2 reviewers (S.A.S., J.D.) in a systematic way,
screening through titles and abstracts, followed by full-
text using predefined inclusion and exclusion criteria
(see Figure 1). We resolved any disagreement by dis-
cussion and consulting a third individual (M.C-Y.) as
necessary.
The studies were analyzed using thematic content
analysis—the most common method adopted within
narrative reviews to synthesize findings across the in-
cluded studies. Guided by the research questions, recur-
rent themes across the included studies were identified
and tabulated under thematic headings to inform read-
ers of extracted key points of the findings.33,34 Findings
were summarized on the basis of the following:
1. Setting(s) of the study—delivered in the NICU,
postdischarge, or both.
2. Methodology of the study—methodology used,
such as randomized controlled trials (RCTs),
questionnaire-based, or observational-based
studies.
3. Outcomes of the study—parental and/or neonatal
outcomes as a result of the intervention, including
usability and feasibility, perceived benefits, and
neonatal health.
Description of studies
The systematic search identified 2218 unique citations
after removal of duplicates. Titles and abstracts of all
identified articles were screened and reviewed for rele-
vance to the study criteria, 2184 articles were excluded,
resulting in 34 articles for possible inclusion. Full-text of
the 34 articles was reviewed for meeting the eligibility
criteria. From this, 10 articles were identified for inclu-
sion (see the Figure). Articles were excluded for several
reasons: study not performed in the NICU (n = 3), de-
scriptive studies (n = 13), study proposal (n = 1), article
written in language other than English (n = 2), wrong
comparator (eg, examining nurses’ perspective instead
of parents’ (n = 1); review article (n = 2); wrong in-
tervention (eg, evaluating the content of Facebook sup-
port groups, n = 1); or wrong outcomes (eg, studying
the experiences of parents using social networking sites
to facilitate personal exchange, n = 1). The 10 stud-
ies identified for inclusion fell into 4 different design
categories. Two RCTs, 2 qualitative descriptive studies,
2 observational studies, and 4 questionnaire/survey-
based studies were included in the review. All but 2
of the 10 included studies described interventions that
were conducted in the NICU as compared with postdis-
charge. There was a wide variation of reported sample
sizes among the studies, ranging from n = 10 to n =
320 (see Table 2).

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 Table 2. Summary of design and measures in the included studies
Study

Author Year Design Sample, n Setting Outcome measures

30
Gray et al 2000 RCT 56 NICU and postdischarge Family satisfaction survey;
chart review (LOS)
Gund et al37 2013 RCT 34 Postdischarge Parental questionnaire
Lindberg et al14,26 2009 Qualitative 10 Postdischarge Interview
De Rouck and Leys40 2013 Qualitative 40 NICU Interview
Rhoads et al38 2015 Observational 320 NICU # of log-ons and viewing time
Safran et al7 2005 Observational 235 NICU and postdischarge Chart review (LOS)
Alfaleh et al35 2011 Questionnaire 10 NICU Knowledge scale
questionnaire
Choi and Bakken36 2010 Questionnaire 10 NICU Usability test
Epstein et al11 2015 Questionnaire 15 NICU PPUS; feasibility survey
Hawkes et al39 2015 Questionnaire 99 NICU Parental questionnaire

Abbreviations: LOS, length of stay; PPUS, Penticuff’s Parents’ Understanding Survey; RCT, randomized controlled trials.

Effects of interventions ents. Furthermore, the mean number of times parents

Five themes emerged from the results of the 10 included
studies: (i) usability and feasibility; (ii) parental satisfac-
tion and perceived benefits; (iii) infant’s hospital length
of stay; (iv) knowledge uptake; and (v) predictors of
variations in use of eHealth (see Table 3).
Usability and feasibility
Five studies demonstrated usability and feasibility of
eHealth.11,35–38 Choi and Bakken36 reported that study
participants’ (parents of preterm infants; n = 10) per-
ceived ease of use and usefulness score to be 4.52 out
of 5-point Likert-type scale from 1 (strongly disagree)
to 5 (strongly agree), indicating that participants found
the educational Web site for low literate parents easy
to use and useful.
Gund et al,37 exploring the impact of videoconfer-
encing or Web applications on parent’s satisfaction on
home healthcare of their premature infants, found that
all parents found the eHealth technology easy to use.
Participants (n = 34) in the 2 intervention groups (using
Web application or Skype) expressed the ease of use,
pointing out features such as infant’s data in graphic
form, that led participants to come to that conclusion.37
All parents (n = 15) in the Epstein et al11 study found
the daily Skype or FaceTime updates to be reliable and
easy to use between the NICU and parents at home.
Approximately 80% of parents identified the video and
audio quality as either excellent or good but identified
frozen screens and missed updates due to scheduling
problems as challenges of the intervention.
Rhoads et al38 determined that both mothers (n =
219) and fathers (n = 101) equally utilize the Web
cameras while their neonates are hospitalized and con-
cluded that technology does not pose a barrier to par-
logged on to use the Web cameras for mothers (n =
95.0, SD = 152.2) and fathers (n = 95.7, SD = 190.8)
was similar, suggesting that neither mothers or fathers
faced barriers related to utilizing the option of Web
cameras when their neonates were in the hospital.
Participants in a computer-based Decision Aid (DA)
program to determine parents’ preferences with regard
to a treatment of their infants (n = 10) provided positive
feedback on the understandability and user friendliness
of the program.35 Parents rated 10 of 13 items of the
DA positively while showing significant improvement
on knowledge and decisional conflict.
Parental satisfaction and perceived benefits
Four studies examined parental satisfaction and per-
ceived benefits of eHealth technology in infant
care.26,30,37,39 Parents (n = 26) included in the interven-
tion group (receiving Baby CareLink educational World
Wide Web pages and daily reports) were more satisfied
on the quality of care and less likely to report issues
(eg, NICU visitation policy) than the control group (re-
ceived information and support as normally provided in
the NICU), although both groups were exposed to the
same NICU environment (eg, following the same NICU
visitation policy).30 The perceived benefits expressed by
participants included reducing level of stress,39 webcam
reducing the number of phone calls to the unit,37 feel-
ing secure in caring for own infant at home,26,37 and a
sense of staff’s presence and ability to read staff’s body
language.30
Neonatal indicator—Infant’s length of stay
Two studies examined the neonatal health indicator
through the length of stay at the hospital based on

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 Table 3. Summary of outcomes in the included studies
Outcomes

Parental
Usability satisfaction and Predictors of
and perceived Length Knowledge variations in use
Author Year feasibility benefits of stay uptake of eHealth
35
√ √
Alfaleh et al 2011
√
Choi and Bakken36 2010
√ √
Epstein et al11 2015
√ √
Gray et al30 2000
√ √
Gund et al37 2013
√
Hawkes et al39 2015
√
Lindberg et al14,26 2009
√ √
Rhoads et al38 2015
√
De Rouck and Leys40 2013
√
Safran et al7 2005

access to Baby CareLink, which is an eHealth initiative
that allowed parents to be remotely involved in deci-
sions related to their infant’s care in the NICU through
videoconferencing and Internet technologies.7,30 Al-
though not statistically significant (P ≥ .05), Gray et al30
reported that infants in the CareLink group (n = 26)
remained for a shorter period of time at the hospital
than their control group counterparts (receiving regular
care; n = 30), that is, 68.5 ± 28.3 days versus 70.6 ±
35.6 days, respectively. Greater difference in length of
stay was observed in infants born weighing less than
1000 g (77.4 ± 26.2 days vs 93.1 ± 35.6 days; P ≥ .05),
and all infants who received Baby CareLink were dis-
charged directly to home whereas 20% of control infants
were discharged first to community hospitals before
being discharged home.30 In addition, more frequent
use of Baby CareLink was associated with significantly
shorter length of stay (15.4 days sooner), even more
so in families with lower socioeconomic status, that is,
Medicaid families.7 Specifically, if Medicaid families ac-
cessed the Baby CareLink educational pages 3 or more
times per day, they took their infants home 17.5 days
sooner.7
Knowledge uptake
Two studies examined parental knowledge uptake fol-
lowing the intervention.11,35 Significant improvement in
the knowledge scale score after review of the DA pro-
gram was determined, with a score of 1.7 (out of 10)
preintervention to a score of 7.6 postintervention.35 In
contrast, total scores of the Penticuff’s Parents’ Un-
derstanding Survey before and after the intervention
did not differ significantly in the study performed by
Epstein et al.11 However, scores on the first and sec-
ond subcategories of the survey (broad views of having
the infant in the NICU and specific parent experiences)
showed significant difference before and after the inter-
vention. The other subcategory, which addressed the
presence of problems common to preterm infants and
the degree of parent worry about problems, did not
show significant clinical difference before and after the
intervention.
Predictors of variations in use of eHealth
Two studies investigated the predictors of variations in
the utilization of eHealth.38,40 Rhoads et al38 found no
difference in the total viewing time and use of Web
cameras by mothers and fathers to view their infant.
When comparing mother and fathers of the same infant,
mothers (n = 80.3, SD = 92.3) reported significantly
more log-ins than fathers (n = 46.2, SD = 61.9), yet the
amount of total viewing time was not statistically differ-
ent. Therefore, in contrast to previous studies’ findings
demonstrating less NICU visitations by fathers than by
mothers, there did not seem to be a difference in the
amount of use of Web cameras to view the infant, ex-
cept that mothers tended to log-in more.41
De Rouck and Leys40 identified illness trajectory as
a trigger to use the Internet as a health information
tool. Components of illness trajectory influencing such
use were attributed to the presence of biomedical
events; perceived problems characterized by sudden

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appearance; biomedical seriousness of a problem im-
pact; timing of complication appearance; relationship
with healthcare professionals; emotional reactions to
unfamiliarity, unpredictability, uncertainty, and anxi-
ety; event or biomedical labeling and search behavior;
expectations about Internet information; and learning
along the illness trajectory.
DISCUSSION
This scoping review demonstrates that overall, parents
would like to see the integration of eHealth in the de-
livery of care for their infants and expressed the ease
to use such technologies, with all of its actual and per-
ceived benefits to both parents and infants. Two RCTs,
2 qualitative descriptive studies, 2 observational stud-
ies, and 4 questionnaire/survey-based studies were in-
cluded, representing acceptability, feasibility, parental
perceptions, and predictors of variations in the utiliza-
tion of eHealth. No studies have investigated the im-
pact of eHealth in facilitating parental participation in
the NICU, nor examined the direct influence of eHealth
on neonatal health outcomes such as rate of infection.
The small sample size in many of the studies neces-
sitates future research to employ larger sample size
to provide higher confidence in generalization of re-
sults. Specifically, only 3 of the 10 studies had sample
sizes above 50, limiting the ability of these studies to
find significant power to determine statistically differ-
ences. Furthermore, only 2 of the 10 studies conducted
RCTs, with the majority of studies using methods that
limit generalization or extrapolation beyond the specific
context. This is understandable with the need to under-
stand usability and feasibility of novel eHealth technolo-
gies; however, future studies should also utilize more
rigorous methodologies, such as RCTs, phenomeno-
logical, or grounded theory study, to explore the
wider benefits of eHealth technology for parents in the
NICU.
The analysis showed that parents are willing to use
eHealth in the delivery of care to their infants, and,
in fact, the majority of parents do not perceive any
barriers in utilizing eHealth. Furthermore, the use of
eHealth enhances the family experience and satisfac-
tion during what could be described as emotionally
distressing experience in the NICU, as observed in the
difference in the level of parental satisfaction between
the control and intervention groups despite the same
NICU policy (eg, visitation hours).37 A previous study
by Minton et al8 demonstrated that parents may also
prefer one type of communication technology over the
other, for instance, videoconferencing versus telephone
discussion, due to accommodation of visual contact,
ability to record or repeat message, and opportunities
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to ask questions, particularly when parents are not
present for direct discussion following physician’s daily
evaluations of the baby. Despite verbalization of such
acceptability of eHealth, parents also confirmed that
integration of eHealth complements but should not
fully replace face-to-face interaction.26 These findings
concur with previously reported parental perceptions
in the use of eHealth in similar critical situation in
pediatric settings or postpartum period: enhanced
parental satisfaction and self-efficacy.27,42 Moreover,
these findings agree with preliminary evidence of
eHealth use to enhance parents’ experience and other
studies on the wider use of eHealth (eg, neonatal
resuscitation).8,43,44
Although included studies examined parental
perception and perceived benefits, no studies tested
on how the interventions translate into improving
health-seeking or care behaviors of parents, specifically
in direct parental participation in infant care. Previous
studies have shown the impact of parent involve-
ment in both parental well-being and infant health
outcomes, including shorter length of stay, positive
brain development in infant, and positive parent-infant
relationship.4,9,45–48 Therefore, further studies are
recommended to investigate the influence of eHealth
on health-seeking and care behaviors of parents to
better understand its impacts on parental and neonatal
health outcomes. In addition, future studies should
focus on confirming significant relationship between
eHealth use and indicators of health outcomes (eg,
hospital length of stay) and investigating the rationale
for such relationship.
CONCLUSION
This review provides further insights into the feasibility
and acceptability of eHealth intervention in the NICU
by parents. The evidence demonstrated actual and per-
ceived benefits of eHealth for parents of infants ad-
mitted into the NICU: usability, parental satisfaction,
confidence in infant care, and parental knowledge up-
take. Although there appears to be some evidence that
a significant decrease in infant’s length of stay is cor-
related with more frequent utilization of eHealth, fur-
ther studies measuring direct neonatal health outcomes
(eg, infant rate of infection, parental and neonatal fac-
tors, timing of eHealth utilization) are recommended to
better understand the benefits of eHealth on neonatal
health. The goal of access to eHealth should not lessen
the need for parents to be present at the bedside but
to set up a way that parents and caregivers can access
information related to the direct care and health of their
infants at their own time and pace, whether or not they
are in the hospital.
October/December 2017
References
1. Reynolds LC, Duncan MM, Smith GC, et al. Parental presence
and holding in the neonatal intensive care unit and associa-
tions with early neurobehavior. J Perinatol. 2016;33:636–641.
2. Vinall J, Miller SP, Synnes AR, Grunau RE. Parent behav-
iors moderate the relationship between neonatal pain and
internalizing behaviors at 18 months corrected age in chil-
dren born very prematurely. Pain. 2013;154:1831–1839.
3. Jahromi LB, Putnam SP, Stifter CA. Maternal regulation of in-
fant reactivity from 2 to 6 months. Dev Psychol. 2004;40:477–
487.
4. Ray JG, Urquia ML, Berger H, Vermeulen MJ. Maternal and
neonatal separation and mortality associated with concur-
rent admissions to intensive care units. CMAJ. 2012;184:E956–
E962.
5. Grosik C, Snyder D, Cleary GM, Breckenridge DM, Tidwell
B. Identification of internal and external stressors in par-
ents of newborns in intensive care. Perm J. 2013;17(3):36–41.
doi:10.7812/TPP/12-105.
6. Safran C, Charles S. The collaborative edge: patient empow-
erment for vulnerable populations. Int J Med Inform. 2003;
69(2/3):185–190. doi:10.1016/s1386-5056(02)00130-2.
7. Safran C, Pompilio-Weitzner G, Emery KD, Hampers L. Col-
laborative approaches to e-Health: valuable for users and
non-users. Stud Health Technol Inform. 2005;116:879–884.
8. Minton S, Allan M, Valdes W. Teleneonatology: a major
tool for the future. Pediatr Ann. 2014;43(2):e50–e55. doi:10
.3928/00904481-20140127-11.
9. Cooper LG, Gooding JS, Gallagher J, Sternesky L, Ledsky
R, Berns SD. Impact of a family-centered care initiative on
NICU care, staff and families. J Perinatol. 2007;27:32–37.
doi:10.1038/sj.jp.7211840.
10. Dunn MS, Reilly MC, Johnston AM, Hoopes RD, Abraham MR.
Development and dissemination of potentially better prac-
tices for the provision of family-centered care in neonatology:
the family-centered care map. Pediatrics. 2006;118(suppl
2):S95–S107. doi:10.1542/peds.2006-0913F.
11. Epstein EG, Sherman J, Blackman A, Sinkin RA. Testing the
feasibility of Skype and FaceTime updates with parents in the
neonatal intensive care unit. Am J Crit Care. 2015;24(4):290–
296.
12. Harrison H. The Principles for family-centered neonatal care.
Pediatrics, 1993;92(5):643–650.
13. Cleveland LM. Parenting in the neonatal intensive care
unit. J Obstet Gynecol Neonatal Nurs. 2008;37(6):666–691.
doi:10.1111/j.1552-6909.2008.00288.x.
14. Lindberg B, Axelsson K, Ohrling K. Experience with video-
conferencing between a neonatal unit and the families’ home
from the perspective of certified paediatric nurses. J Telemed
Telecare. 2009;15(6):275–280. doi:10.1258/jtt.2009.090112.
15. White RD, Smith JA, Shepley MM; Committee to Estab-
lish Recommended Standards for Newborn, I.C.U.D. Recom-
mended standards for newborn ICU design, eighth edition.
J Perinatol. 2013;33(suppl 1):S2–S16. doi:10.1038/jp.2013.10.
16. Brazy JE, Anderson BM, Becker PT, Becker M. How par-
ents of premature infants gather information and obtain
support. Neonatal Netw. 2001;20(2):41–48. doi:10.1891/0730-
0832.20.2.41.
17. Jiang S, Warre R, Qiu X, O’Brien K, Lee SK. Parents as practi-
tioners in preterm care. Early Hum Dev. 2014;90(11):781–785.
doi:10.1016/j.earlhumdev.2014.08.019.
18. Gabbert TI, Metze B, Bührer C, Garten L. Use of social
networking sites by parents of very low-birth-weight in-
fants: experiences and the potential of a dedicated site. Eur
J Pediatr. 2013;172(12):1671–1677. doi:10.1007/s00431-013-
2067-7.
19. Hussey P, Adams E, Shaffer FA. Nursing informatics and
leadership, an essential competency for a global priority:
The Journal of Perinatal & Neonatal Nursing
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
eHealth. Nurse Leader. 2015;13(5):52–57. doi:10.1016/j.mnl
.2015.07.002.
20. Free C, Phillips G, Galli L, et al. The effectiveness of
mobile-health technology-based health behaviour change
or disease management interventions for health care con-
sumers: a systematic review. PLoS Med. 2013;10(1):e1001362.
doi:10.1371/journal.pmed.1001362.
21. Bradford NK, Armfield NR, Young J, Smith AC. Paediatric pal-
liative care by video consultation at home: a cost minimisa-
tion analysis. BMC Health Serv Res. 2014;14:328. doi:10.1186/
1472-6963-14-328.
22. Oh H, Rizo C, Enkin M, Jadad A. What is eHealth (3): a
systematic review of published definitions. J Med Internet
Res. 2005;7(1):1–11. doi:10.2196/jmir.7.1.e1.
23. Dhillon AS, Albersheim SG, Alsaad S, Pargass NS, Aupan-
cic J. Internet use and perceptions of information reliabil-
ity by parents in a neonatal intensive care unit. J Perinatol.
2003;23(5):420–424. doi:10.1038/sj.jp.7210945.
24. Niela-Vilén H, Axelin A, Melender HL, Salanterä S. Aiming to
be a breast-feeding mother in a neonatal intensive care unit
and at home: a thematic analysis of peer-support group dis-
cussion in social media. Matern Child Nutr. 2015;11(4):712–
726. doi:10.1111/mcn.12108.
25. Thibeau S, Ricouard D, Gilcrease C. Innovative technol-
ogy offers virtual visitation for families. J Contin Educ Nurs.
2012;43(10):439–440. doi:10.3928/00220124-20120925-94.
26. Lindberg I, Christensson K, Öhrling K. Parents’ experi-
ences of using videoconferencing as a support in early dis-
charge after childbirth. Midwifery. 2009;25(4):357–365. doi:10
.1016/j.midw.2007.06.002.
27. Marcin JP, Schepps DE, Page KA, Struve SN, Nagrampa E,
Dimand RJ. The use of telemedicine to provide pediatric crit-
ical care consultations to pediatric trauma patients admitted
to a remote trauma intensive care unit. Pediatr Crit Care
Med. 2004;5(3):251–256. doi:10.1097/01.PCC.0000123551
.83144.9E.
28. UAMS helps hospital with broadband link between parents,
premature babies. Angel Eye Web site. https://www.
uamshealth.com/news/?id=5350&sid=1&nid=9713&cid=5.
Accessed December 20, 2015.
29. Welcome to the Angel Eye program. University of Arkansas
for Medical Sciences Web site. www.uams.edu/angeleye.
Accessed December 20, 2015.
30. Gray J, Safran C, Davis R, et al. Baby CareLink: using the In-
ternet and telemedicine to improve care for high-risk infants.
Pediatrics. 2000;106(6):1318–1324.
31. Arksey H, O’Malley L. Scoping studies: towards a method-
ological framework. Int J Soc Res Methodol. 2005;8(1):19–32.
doi:10.1080/1364557032000119616.
32. Levac D, Colquhoun H, O’Brien KK. Scoping studies: advanc-
ing the methodology. Implement Sci. 2010;5:69. doi:10.1186/
1748-5908-5-69.
33. Kastner M, Tricco AC, Soobiah C, et al. What is the most
appropriate knowledge synthesis method to conduct a re-
view? Protocol for a scoping review. BMC Med Res Methodol.
2012;12(1):114. doi:10.1186/1471-2288-12-114.
34. Mays N, Pope C, Popay J. Systematically reviewing qual-
itative and quantitative evidence to inform management
and policy-making in the health field. J Health Serv
Res Policy. 2005;10(suppl 1):6–20. doi:10.1258/1355819054
308576.
35. Alfaleh KM, Al Luwaimi E, Alkharfi TM, Al-Alaiyan SA.
decision aid for considering indomethacin prophylaxis vs.
symptomatic treatment of PDA for extreme low-birth-weight
infants. BMC Pediatr. 2011;11(1):78. doi:10.1186/1471-2431-
11-78
36. Choi J, Bakken S. Web-based education for low-literate
parents in neonatal intensive care unit: development of
www.jpnnjournal.com 339
 a website and heuristic evaluation and usability testing.
Int J Med Inform. 2010;79(8):565–575. doi:10.1016/j.ijmedinf
.2010.05.001.
37. Gund A, Sjöqvist BA, Wigert H, Hentz E, Lindecrantz K, Bry
K. A randomized controlled study about the use of eHealth
in the home health care of premature infants. BMC Med
Inform Decis Making. 2013;13:22. doi:10.1186/1472-6947-
13-22.
38. Rhoads SJ, Green A, Gauss CH, Mitchell A, Pate B. Web
camera use of mothers and fathers when viewing their hos-
pitalized neonate. Adv Neonatal Care. 2015;15(6):440–446.
doi:10.1097/ANC.0000000000000235.
39. Hawkes GA, Livingstone V, Ryan CA, Dempsey EM. Per-
ceptions of webcams in the neonatal intensive care unit:
here’s looking at you kid! Am J Perinatol. 2015;30(2):131–
136. doi:http://dx.doi.org/10.1055/s-0034-1376388.
40. De Rouck S, Leys M. Illness trajectory and Internet as a health
information and communication channel used by parents of
infants admitted to a neonatal intensive care unit. J Adv Nurs.
2013;69(7):1489–1499. doi:10.1111/jan.12007.
41. Garten L, Maass E, Schmalisch G, Bührer C. O father,
where art thou? J Perinat Neonatal Nurs. 2011;25(4):342–348.
doi:10.1097/JPN.0b013e318233b8c3.
42. Salonen AH, Kaunonen M, Åstedt-Kurki P, Järvenpää AL,
Isoaho H, Tarkka MT. Effectiveness of an internet-based
340 www.jpnnjournal.com
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
intervention enhancing Finnish parents’ parenting satis-
faction and parenting self-efficacy during the postpartum
period. Midwifery. 2011;27(6):832–841. doi:10.1016/j.midw
.2010.08.010.
43. Phillips M. Telemedicine in the neonatal intensive care unit.
Pediatr Nurs. 1999;25(2):185–186, 189.
44. Tan K, Lai NM. Telemedicine for the support of parents
of high risk newborn infants. Cochrane Database Syst Rev.
2012;(6):CD006818.
45. Flacking R, Lehtonen L, Thomson G, et al. Closeness
and separation in neonatal intensive care. Acta Pae-
diatr. 2012;101(10):1032–1037. doi:10.1111/j.1651-2227.2012
.02787.x.
46. Franck LS, Oulton K, Nderitu S, Lim M, Fang S, Kaiser A.
Parent involvement in pain management for NICU infants: a
randomized controlled trial. Pediatrics. 2011;128(3):510–518.
doi:10.1542/peds.2011-0272.
47. Lee S, O’Brien K. Practice care unit. CMAJ. 2014;186(11):845–
847.
48. Melnyk BM, Feinstein NF, Alpert-Gillis L, et al. Reducing pre-
mature infants’ length of stay and improving parents’ mental
health outcomes with the Creating Opportunities for Parent
Empowerment (COPE) neonatal intensive care unit program:
a randomized, controlled trial. Pediatrics. 2006;118(5):e1414–
e1427. doi:10.1542/peds.2005-2580.
October/December 2017